End-stage renal disease: a profile of facilities furnishing treatment.

Medicare and end-stage renal disease (ESRD)

The Medicare ESRD program is designed to assure qualifying beneficiaries access to high quality, cost-effective medical care. To a large extent, it has succeeded. Today, over 90 percent of all patients being treated for ESRD ultimately receive some Medicare reimbursement.

This report discusses the growth in the number of participating renal facilities furnishing some form of ESRD treatment. (See glossary for definition of terms.)

Since the ESRD program began in 1973, the total number of renal facilities has more than doubled to 1,309 in 1983. From 1982 to 1983 alone, there were 7.5 percent more participating ESRD facilities.

The growth in the number of renal facilities has been primarily among freestanding units, i.e., units not affiliated with hospitals. In 1973, freestanding units represented about one out of nine renal facilities (11.2 percent); hospital units or hospital satellites made up the remaining eight out of nine (88.8 percent). By 1983, almost one out of every two renal facilities (47.9 percent) was freestanding.

In 1983, almost four out of every ten (38.5 percent) renal facilities were proprietary and were almost exclusively freestanding. Proprietary facilities represent an increasing proportion of all facilities.

Nonprofit renal facilities, on the other hand, are mainly hospital based (that is, either hospital units or hospital satellites).

In 1983, just over 6,000 renal transplants were performed in 155 renal hospital units called “transplant centers.” (A total of 159 units were actually approved to perform transplants.) All but 13 of these transplant centers also provide outpatient dialysis services.

Patients not receiving kidney transplants receive dialysis care either at home or at one of the 1,296 renal facilities providing at least one dialysis service. The overwhelming majority (1,247) of these facilities provide care in a predominantly outpatient setting. Of this number, 738 are “dialysis facilities,” which means they are approved to furnish at least one dialysis service. These facilities may be in either a hospital (111) or nonhospital (627) setting.

Another 509 locations are called “dialysis centers” as opposed to dialysis facilities. These are hospital units which, in addition to providing dialysis service(s), are also approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services. Of the total number of dialysis centers, 146 are also transplant centers.

Finally, 49 renal dialysis centers are defined as “inpatient care” centers because they provide backup dialysis services only, and 20 percent or less of their dialysis is performed on an outpatient basis.

There is over a threefold variation in the proportion of all facilities that are freestanding, from a low of 22 percent in New York to a high of 75 percent in Atlanta.

Most of the services and supplies needed by people with permanent kidney failure are covered only by supplementary medical insurance (SMI)—e.g., outpatient maintenance dialysis, self-dialysis training, and home dialysis. While the number of ESRD SMI enrollees varies considerably by region (Figure 2), ESRD enrollees as a percent of total enrollees is relatively constant across regions (Figure 3).

Figure 2

Medicare: Number of supplementary medical insurance end-stage renal disease enrollees, by region: July 1983

Figure 3

Medicare: End-stage renal disease as a percent of total supplementary medical insurance enrollees, by region: July 1983

The number of dialysis stations per 1,000 ESRD SMI enrollees varies significantly by region, from a low of 110 in Seattle to a high of 225 in Denver; however, those regions such as Seattle with low outpatient dialysis stations may have a high home dialysis population.

Table 1

Number of certified end-stage renal disease providers or facilities, by type of ownership and type of facility: 1980-83

	1980		1981		1982		1983
	Number	Percent	Number	Percent	Number	Percent	Number	Percent
All facilities	1,073	100.0	1,162	100.0	1,218	100.0	1,309	100.0
Proprietary	323	30.1	408	35.1	437	35.9	504	38.5
Hospital based	23	2.1	21	1.8	14	1.1	14	1.1
Hospitals	23	2.1	21	1.8	14	1.1	14	1.1
Hospital satellites	0	0.0	0	0.0	0	0.0	0	0.0
Freestanding	300	28.0	387	33.3	423	34.7	490	37.4
Nonprofit	750	69.9	754	64.9	781	64.1	805	61.5
Hospital based	620	57.8	655	56.4	677	55.6	668	51.0
Hospitals	593	55.3	625	53.8	643	52.8	638	48.7
Hospital satellites	27	2.5	30	2.6	34	2.8	30	2.3
Freestanding	130	12.1	99	8.5	104	8.5	137	10.5

Table 2

Number of certified end-stage renal disease facilities and centers, by type of facility or center, type of service, and Health Care Financing Administration (HCFA) administrative region: December 1983

HCFA administrative region	Total facilities and centers1(1)	Transplant			Dialysis							Approved dialysis stations
		All hospital transplant centers2(2)	Hospital transplant only centers(3)	Hospital dialysis and transplant centers(4)	All suppliers3(5)	Inpatient hospital care(6)	Primarily outpatient					Number(12)	Per 1,000 enrollees
							Total facilities and centers4(7)	Hospital dialysis only center(8)	Hospital dialysis facilities(9)	Hospital dialysis and transplant centers(10)	Nonhospital dialysis facilities(11)
All regions	1,309	159	13	146	1,296	49	1,247	363	111	146	627	15,511	181
Boston	53	11	0	11	53	0	53	26	2	11	14	602	132
New York	130	18	2	16	128	0	128	79	5	16	28	1,476	127
Philadelphia	176	20	0	20	176	7	169	49	7	20	93	2,091	214
Atlanta	257	21	1	20	256	11	245	21	12	20	192	3,428	210
Chicago	202	33	1	32	201	11	190	76	30	32	52	2,499	165
Dallas	176	20	3	17	173	5	168	35	16	17	100	2,018	218
Kansas City	52	10	1	9	51	0	51	14	13	9	15	569	155
Denver	45	3	0	3	45	4	41	11	8	3	19	400	225
San Francisco	189	18	2	16	187	10	177	43	18	16	100	2,194	188
Seattle	29	5	3	2	26	1	25	9	0	2	14	234	110

Unduplicated count of all certified ESRD facilities and centers = (3) + (4) + (6) + (7) + (8) + (9) + (11); column (10) is not counted again as it is a repeat of column (4).

All hospital transplant centers = (3) + (4).

All dialysis suppliers = (6) + (7).

Total facilities and centers primarily providing outpatient dialysis = (8) + (9) + (10) + (11).

Total dialysis facilities (including hospital and freestanding) = (9) + (11).

NOTES:

Total hospital based facilities and centers (including transplant, inpatient dialysis and outpatient dialysis) = (3) + (4) + (6) + (8) + (9); column (10) is not counted again as it is a repeat of column (4).