Healthcare systems and end-stage renal disease (ESRD) therapies - an international review: costs and reimbursement/funding of ESRD therapies

Background. In healthcare economics, the cost factor plays a leading role, particularly for chronic diseases such as end-stage renal disease because o f the growing number of patients. Objectives. An international comparison was made of the costs and reimburse ment/funding of a selection of key dialysis modalities-centre haemodialysis (CHD), limited care haemodialysis (LCHD), home haemodialysis (home HD), co ntinuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dia lysis (APD)-in various industrial countries. The focus was on treatment cos ts plus erythropoietin medication and reimbursement of transportation costs . Results. Reimbursement/funding of dialysis is different from country to cou ntry, with some healthcare system-specific commonalities: in 'public' syste ms, the funding is based more on global budgets, whereas in mixed public an d private countries it is based mainly on reimbursement rates per treatment . Only in the 'private system' of the US is there one DRG (diagnostic-relat ed group)-type rate for dialysis. By comparing the costs (in public countri es) or reimbursements (in mixed countries) of treatment modalities within e ach country, we could see similar curves: the costs were the highest for pu blic CHD, followed by private CHD. They were lower on LCHD and the lowest f or home HD and CAPD, which were at nearly the same level. The cost level fo r APD was almost the same as that of LCHD. The reimbursements followed the cost pattern. Some countries introduced increases for CAPD and APD with the intention of increasing the share of home care. The costs and reimbursemen t patterns in the majority of countries (except the US and Japan) were very similar and therefore did not explain the different distribution of modali ties in these countries. One explanation could be, however, the difference in microeconomics, CHD being a treatment with high fixed costs (personnel a nd structure) and CAPD being a treatment with low fixed costs, but high var iable costs (supplies) and a low need for investments. Discussion. The choice of treatment modality seems to be influenced strongl y by the provider's perspective, being either public with limited HD capaci ty or private having invested in HD capacity. For public providers (and hea lthcare payers), CAPD is less expensive than CHD and offers a number of pot ential savings. In many countries, two CAPD patients could be treated for t he same costs as one CHD patient. The microeconomics of private centres, ho wever, are meant to use the investments maximally for CHD. Only if capacity limits are reached, is PD, with mainly supply costs, interesting. The futu re with constantly increasing numbers of patients and growing cost constrai nts will force all providers to make the best use of their resources by als o offering home therapies such as PD to patients. The latter are cost effic ient and offer comparable survival and quality of life.