Medicaid Expansion and Medicare-Financed Hospitalizations Among Adult Patients With Incident Kidney Failure.

Importance: Although Medicare provides health insurance coverage for most patients with kidney failure in the US, Medicare beneficiaries who initiate dialysis without supplemental coverage are exposed to substantial out-of-pocket costs. The availability of expanded Medicaid coverage under the Patient Protection and Affordable Care Act (ACA) for adults with kidney failure may improve access to care and reduce Medicare-financed hospitalizations after dialysis initiation. Objective: To examine the implications of the ACA's Medicaid expansion for Medicare-financed hospitalizations, health insurance coverage, and predialysis nephrology care among Medicare-covered adults aged 19 to 64 years with incident kidney failure in the first year after initiating dialysis. Design, Setting, and Participants: This cross-sectional study used a difference-in-differences approach to assess Medicare-financed hospitalizations among adults aged 19 to 64 years who initiated dialysis between January 1, 2010, and December 31, 2018, while covered by Medicare Part A (up to 5 years postexpansion). Data on patients were obtained from the Renal Management Information System's End Stage Renal Disease Medical Evidence Report, which includes data for all patients initiating outpatient maintenance dialysis regardless of health insurance coverage, treatment modality, or citizenship status, and these data were linked with claims data from the Medicare Provider Analysis and Review. Data were analyzed from January to August 2022. Exposure: Living in a Medicaid expansion state. Main Outcomes and Measures: Primary outcomes were number of Medicare-financed hospitalizations and hospital days in the first 3 months, 6 months, and 12 months after dialysis initiation. Secondary outcomes included dual Medicare and Medicaid coverage at 91 days after dialysis initiation and the presence of an arteriovenous fistula or graft at dialysis initiation for patients undergoing hemodialysis. Results: The study population included 188 671 adults, with 97 071 living in Medicaid expansion states (mean [SD] age, 53.4 [9.4] years; 58 329 men [60.1%]) and 91 600 living in nonexpansion states (mean [SD] age, 53.0 [9.6] years; 52 677 men [57.5%]). In the first 3 months after dialysis initiation, Medicaid expansion was associated with a significant decrease in Medicare-financed hospitalizations (-4.24 [95% CI, -6.70 to -1.78] admissions per 100 patient-years; P = .001) and hospital days (-0.73 [95% CI, -1.08 to -0.39] days per patient-year; P < .001), relative reductions of 8% for both outcomes. Medicaid expansion was associated with a 2.58-percentage point (95% CI, 0.88-4.28 percentage points; P = .004) increase in dual Medicare and Medicaid coverage at 91 days after dialysis initiation and a 1.65-percentage point (95% CI, 0.31-3.00 percentage points; P = .02) increase in arteriovenous fistula or graft at initiation. Conclusions and Relevance: In this cross-sectional study with a difference-in-differences analysis, the ACA's Medicaid expansion was associated with decreases in Medicare-financed hospitalizations and hospital days and increases in dual Medicare and Medicaid coverage. These findings suggest favorable spillover outcomes of Medicaid expansion to Medicare-financed care, which is the primary payer for patients with kidney failure.

Changes in Migration and Mortality Among Patients With Kidney Failure in Puerto Rico After Hurricane Maria.

Importance: On September 20, 2017, one of the most destructive hurricanes in US history made landfall in Puerto Rico. Anecdotal reports suggest that many persons with kidney failure left Puerto Rico after Hurricane Maria; however, empirical estimates of migration and health outcomes for this population are scarce. Objective: To assess the changes in migration and mortality among patients with kidney failure in need of dialysis treatment in Puerto Rico after Hurricane Maria. Design, Setting, and Participants: This cross-sectional study used an interrupted time-series design of 6-month mortality rates and migration of 11 652 patients who received hemodialysis or peritoneal dialysis care in Puerto Rico before Hurricane Maria (before October 1, 2017) and/or during and after Hurricane Maria (on/after October 1, 2017). Data analyses were performed from February 12, 2019, to June 16, 2022.. Main Outcomes and Measures: Number of unique persons dialyzed in Puerto Rico per quarter; receipt of dialysis treatment outside Puerto Rico per quarter; and 6-month mortality rate per person-quarter for all persons undergoing dialysis. Exposures: Hurricane Maria. Results: The entire study sample comprised 11 652 unique persons (mean [SD] age, 59 [14.7] years; 7157 [61.6%] men and 4465 [38.4%] women; 10 675 [91.9%] Hispanic individuals). There were 9022 patients with kidney failure and dialysis treatment before and 5397 patients after Hurricane Maria. Before the hurricane, the mean quarterly number of unique persons dialyzed in Puerto Rico was 2834 per quarter (95% CI, 2771-2897); afterwards it dropped to 261 (95% CI, -348 to -175; relative change, 9.2%). The percentage of persons who had 1 or more dialysis sessions outside of Puerto Rico in the next quarter following a previous dialysis in Puerto Rico was 7.1% before Hurricane Maria (95% CI, 4.8 to 9.3). There was a significant increase of 5.8 percentage points immediately after the hurricane (95% CI, 2.7 to 9.0). The 6-month mortality rate per person-quarter was 0.08 (95% CI, 0.08 to 0.09), and there was a nonsignificant increase in level of mortality rates and a nonsignificant decreasing trend in mortality rates. Conclusions and Relevance: The findings of this cross-sectional study suggest there was a significant increase in the number of people receiving dialysis outside of Puerto Rico after Hurricane Maria. However, no significant differences in mortality rates before and after the hurricane were found, which may reflect disaster emergency preparedness among dialysis facilities and the population with kidney failure, as well as efforts from other stakeholders.

Association of Disability Compensation With Mortality and Hospitalizations Among Vietnam-Era Veterans With Diabetes.

Importance: It remains poorly understood whether income assistance for adults with low income and disability improves health outcomes. Objective: To examine the association between eligibility for disability compensation and mortality and hospitalizations among Vietnam-era veterans with diabetes. Design, Setting, and Participants: Quasiexperimental cohort study of a July 1, 2001, policy that expanded eligibility for disability compensation to veterans with "boots on the ground" (BOG) during the Vietnam era on the basis of a diagnosis of diabetes; veterans who were "not on ground" (NOG) remained ineligible. Participants were Vietnam-era veterans with diabetes in the Veterans Affairs Healthcare System. Difference-in-differences were estimated during early (July 1, 2001-December 31, 2007), middle (January 1, 2008-December 31, 2012), and later (January 1, 2013-December 31, 2018) postpolicy periods. Data analysis was performed from October 1, 2020, to December 1, 2021. Exposures: Interaction between having served with BOG (as recorded in Vietnam-era deployment records) and postpolicy period. Main Outcomes and Measures: Primary outcomes were all-cause mortality and hospitalizations. Results: The study population included 14 247 BOG veterans (mean [SD] age at baseline, 51.2 [3.8] years; 25.7% were Black; 3.3% were Hispanic; 63.6% were White; and 6.9% were of other race) and 56 224 NOG veterans (mean [SD] age, 54.2 [6.3] years; 21.7% were Black; 2.1% were Hispanic; 67.1% were White; and 8.2% were of other race). Compared with NOG veterans, BOG veterans received $8025, $14412, and $17 162 more in annual disability compensation during the early, middle, and later postpolicy periods, respectively. Annual mortality rates were unchanged (prepolicy mortality rates: 3.04% for BOG and 3.56% for NOG veterans), with adjusted difference-in-differences of 0.24 percentage points (95% CI, -0.08 to 0.52), -0.08% (95% CI, -0.40 to 0.24), and -0.08% (95% CI, -0.48 to 0.36), during the early, middle, and later postpolicy periods. Among 3623 BOG veterans and 19 174 NOG veterans with Medicare coverage in 1999, a population whose utilization could be completely observed in our data, BOG veterans experienced reductions of -7.52 hospitalizations per 100 person-years (95% CI, -13.12 to -1.92) during the early, -10.12 (95% CI, -17.28 to -3.00) in the middle, and -15.88 (95% CI, -24.00 to -7.76) in the later periods. These estimates represent relative declines of 10%, 13%, and 21%. Falsification tests of BOG and NOG veterans who were already receiving maximal disability compensation prior to the policy yielded null findings. Conclusions and Relevance: In this cohort study, disability compensation among Vietnam-era veterans with diabetes was not associated with lower mortality but was associated with substantial declines in acute hospitalizations. Veterans' disability compensation payments may have important health benefits.

Comparison of mortality between Medicare Advantage and traditional Medicare beneficiaries with kidney failure.

OBJECTIVES: To compare risk-adjusted 1-year mortality between Medicare Advantage (MA) and traditional Medicare (TM) enrollees with kidney failure who initiated dialysis. STUDY DESIGN: Longitudinal analysis of mortality and enrollment data for Medicare beneficiaries. METHODS: The study compared mortality between MA and TM enrollees with kidney failure who initiated dialysis in 2016, accounting for their enrollment switches between MA and TM during 12 months prior to dialysis initiation. Analyses were adjusted for risk scores and fixed effects for the month of dialysis initiation and county of residence. RESULTS: The difference in risk-adjusted 1-year mortality between MA stayers (Medicare beneficiaries who were continuously enrolled in MA prior to dialysis initiation) and TM stayers (those who were continuously enrolled in TM prior to initiating dialysis) was -0.1 percentage points (95% CI, -1.0 to 0.8); however, the difference increased to -1.0 percentage points (95% CI, -3.2 to 1.2) when comparing TM-to-MA switchers (those who switched from TM to MA before initiation) with TM stayers, a comparison more prone to favorable selection bias given our finding that TM-to-MA switchers were healthier than MA stayers. CONCLUSIONS: Among Medicare beneficiaries with kidney failure who initiated dialysis, risk-adjusted 1-year mortality rate is not different between MA and TM stayers. If there is remaining favorable selection in MA due to unobserved health status, our finding provides a lower-bound estimate of the MA impact on mortality among beneficiaries with kidney failure.

Despite National Declines In Kidney Failure Incidence, Disparities Widened Between Low- And High-Poverty US Counties.

National estimates suggest that kidney failure incidence is declining in the US. However, whether this trend is evident in areas with socioeconomic disadvantage is unknown. We examined trends in kidney failure incidence by county-level poverty between 2000 and 2017 and divided the study period into period 1 (2000-05), period 2 (2006-11), and period 3 (2012-17). The magnitude of disparity in kidney failure incidence between high- and low-poverty counties increased from 42.8 more incident cases per million in high-poverty counties in period 1 to 100.1 more in period 3. Despite a national decline, kidney failure incidence increased in high-poverty counties, and disparities between high- and low-poverty counties widened from 2000 to 2017. Achieving the Department of Health and Human Services objective of reducing incident kidney failure cases by 25 percent by 2030 will require focused attention on preventing kidney failure in counties with higher poverty.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Initiation of Kidney Failure Treatment During the First 4 Months of the COVID-19 Pandemic.

Importance: Persons with kidney failure require treatment (ie, dialysis or transplantation) for survival. The burden of the COVID-19 pandemic and pandemic-related disruptions in care have disproportionately affected racial and ethnic minority and socially disadvantaged populations, raising the importance of understanding disparities in treatment initiation for kidney failure during the pandemic. Objective: To examine changes in the number and demographic characteristics of patients initiating treatment for incident kidney failure following the COVID-19 pandemic by race and ethnicity, county-level COVID-19 mortality rate, and neighborhood-level social disadvantage. Design, Setting, and Participants: This cross-sectional time-trend study used data from US patients who developed kidney failure between January 1, 2018, and June 30, 2020. Data were analyzed between January and July 2021. Exposures: COVID-19 pandemic. Main Outcomes and Measures: Number of patients initiating treatment for incident kidney failure and mean estimated glomerular filtration rate (eGFR) at treatment initiation. Results: The study population included 127 149 patients with incident kidney failure between January 1, 2018, and June 30, 2020 (mean [SD] age, 62.8 [15.3] years; 53 021 [41.7%] female, 32 932 [25.9%] non-Hispanic Black, and 19 835 [15.6%] Hispanic/Latino patients). Compared with the pre-COVID-19 period, in the first 4 months of the pandemic (ie, March 1 through June 30, 2020), there were significant decreases in the proportion of patients with incident kidney failure receiving preemptive transplantation (1805 [2.1%] pre-COVID-19 vs 551 [1.4%] during COVID-19; P < .001) and initiating hemodialysis treatment with an arteriovenous fistula (2430 [15.8%] pre-COVID-19 vs 914 [13.4%] during COVID-19; P < .001). The mean (SD) eGFR at initiation declined from 9.6 (5.0) mL/min/1.73 m2 to 9.5 (4.9) mL/min/1.73 m2 during the pandemic (P < .001). In stratified analyses by race/ethnicity, these declines were exclusively observed among non-Hispanic Black patients (mean [SD] eGFR: 8.4 [4.6] mL/min/1.73 m2 pre-COVID-19 vs 8.1 [4.5] mL/min/1.73 m2 during COVID-19; P < .001). There were significant declines in eGFR at initiation for patients residing in counties in the highest quintile of COVID-19 mortality rates (9.5 [5.0] mL/min/1.73 m2 pre-COVID-19 vs 9.2 [5.0] mL/min/1.73 m2 during COVID-19; P < .001), but not for patients residing in other counties. The number of patients initiating treatment for incident kidney failure was approximately 30% lower than projected in April 2020. Conclusions and Relevance: In this cross-sectional study of US adults, the COVID-19 pandemic was associated with a substantially lower number of patients initiating treatment for incident kidney failure and treatment initiation at lower levels of kidney function during the first 4 months, particularly for Black patients and people living in counties with high COVID-19 mortality rates.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults.

BACKGROUND: Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care. METHODS: Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion). RESULTS: The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period. CONCLUSIONS: The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Association of Medicaid-Focused or Commercial Medicaid Managed Care Plan Type With Outpatient and Acute Care.

Importance: Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown. Objective: To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan. Design, Setting, and Participants: This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020. Interventions: Assignment to a Medicaid-focused insurance plan or a commercial managed care plan. Main Outcomes and Measures: Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations. Results: A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching. Conclusions and Relevance: Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with ESKD.

BACKGROUND AND OBJECTIVES: Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011-when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care-payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans' access to dialysis care and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: An interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA-financed dialysis in community-based dialysis facilities before (2006-2008), during (2009-2010), and after the enactment of VA policies to standardize dialysis payments (2011-2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans' distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period. RESULTS: Before payment reform, the unadjusted average per-treatment reimbursement for non-VA dialysis care varied widely ($47-$1575). After payment reform, there was a 44% reduction ($44-$250) in the adjusted price per dialysis session (P<0.001) and less variation in payments for dialysis ($73-$663). Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to veterans with ESKD from 19 to 37 facilities (per VA hospital), and there were no changes in either the quality of community dialysis facilities or crude 1-year mortality rate of veterans (12% versus 11%). CONCLUSIONS: VA policies to standardize payment and establish national dialysis contracts increased the value of VA-financed community dialysis care by reducing reimbursement without compromising access to care or survival.

Association of Medicaid Expansion With 1-Year Mortality Among Patients With End-Stage Renal Disease.

Importance: The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion. Objective: To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis. Design, Setting, and Participants: Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017. Exposure: Living in a Medicaid expansion state. Main Outcomes and Measures: The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis. Results: A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, -0.8 percentage points; 95% CI, -1.1 to -0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, -0.2 percentage points; 95% CI, -0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of -0.6 percentage points (95% CI, -1.0 to -0.2). Mortality reductions were largest for black patients (-1.4 percentage points; 95% CI, -2.2, -0.7; P=.04 for interaction) and patients aged 19 to 44 years (-1.1 percentage points; 95% CI, -2.1 to -0.3; P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a -4.2-percentage-point (95% CI, -6.0 to -2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant. Conclusions and Relevance: Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.

The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment.

OBJECTIVE: To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. DATA SOURCES: 2011-2016 Medicaid claims from a Northeastern state. STUDY DESIGN: Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. DATA COLLECTION: We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. PRINCIPAL FINDINGS: Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. CONCLUSIONS: Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.

Association of diabetes diagnosis with dietary changes and weight reduction.

BACKGROUND: Lifestyle modifications are associated with better outcomes for patients with diabetes. Patients' awareness of having diabetes may promote lifestyle changes, but there is limited evidence to support this assertion. This study examined whether a report of physician-diagnosed diabetes is associated with dietary changes and efforts to lose weight. METHODS: Cross-sectional comparison of individuals with and without diabetes or prediabetes diagnosis, matched on glycosylated hemoglobin (HbA1c) level, socio-demographic characteristics, and health status using propensity-score matching analysis. Non-pregnant US adult participants (aged 20 and older with an HbA1c level between 5.7% and 7.5%) in the 1999-2014 National Health and Nutrition Examination Survey were included (N = 10,781). RESULTS: Compared with matched controls who did not report having diabetes or prediabetes (N = 1,769), persons with a diagnosis of diabetes or prediabetes (N = 1,769) reported less sugar consumption (14.9 grams [95% CI: 8.9 to 21.0]); less carbohydrate consumption (11.6 grams [95% CI: 1.7 to 21.5]); higher rates of trying to lose weight (12.3 percentage points [95% CI: 5.3 to 19.2]); and a greater one-year weight reduction (4.8 ounces [95% CI: 3.3 to 6.4]). CONCLUSIONS: Awareness of a diagnosis of diabetes or prediabetes from a health profession is associated with the uptake of recommended life-style modifications.

Healthcare investment and income inequality.

This paper examines how the relative shares of public and private health expenditures impact income inequality. We study a two period overlapping generation's growth model in which longevity is determined by both private and public health expenditure and human capital is the engine of growth. Increased investment in health, reduces mortality, raises return to education and affects income inequality. In such a framework we show that the cross-section earnings inequality is non-decreasing in the private share of health expenditure. We test this prediction empirically using a variable that proxies for the relative intensity of investments (private versus public) using vaccination data from the National Sample Survey Organization for 76 regions in India in the year 1986-87. We link this with region-specific expenditure inequality data for the period 1987-2012. Our empirical findings, though focused on a specific health investment (vaccines), suggest that an increase in the share of the privately provided health care results in higher inequality.

Initial Session Duration and Mortality Among Incident Hemodialysis Patients.

BACKGROUND: The association of dialysis session duration with mortality in patients undergoing maintenance hemodialysis is unclear. We compared mortality rates of patients treated in dialysis facilities that used initial session durations of either ≥ 4 versus 3 hours for all incident patients. STUDY DESIGN: Retrospective cohort study. SETTINGS & PARTICIPANTS: Patients with end-stage renal disease beginning maintenance hemodialysis therapy in January 2006 to December 2010 and followed up through December 2012, including 39,172 patients in 852 facilities who initiated treatment for ≥ 4 hours and 47,721 patients in 631 facilities who initiated treatment for 3 hours. PREDICTOR: Initial session duration of ≥ 4 hours versus 3 hours. OUTCOME: 2- and 1-year mortality rates. RESULTS: Total numbers of deaths observed within 2 years after initiating dialysis therapy were 8,945 in the ≥ 4-hour group and 15,624 in the 3-hour group. The corresponding numbers of deaths observed within 1 year were 5,492 and 10,372, respectively. The 2-year adjusted HR in the ≥ 4-hour versus 3-hour group was 0.79 (95% CI, 0.73-0.86). The corresponding 1-year adjusted HR was 0.77 (95% CI, 0.70-0.84). Results were robust when analyses were restricted to specific subgroups of patients classified by age, sex, race, and select clinical characteristics. LIMITATIONS: We did not observe hemodialysis duration in sessions subsequent to initiation. We only included patients treated in facilities with uniform session length (at initiation) for all their patients. Furthermore, we lacked information for dialysis dosage and patients' baseline residual kidney function. CONCLUSIONS: Patients in facilities routinely initiating hemodialysis therapy for ≥ 4 hours may have substantially lower mortality as compared with patients in facilities initiating for only 3 hours of treatment.

Effect of Medicare dialysis payment reform on use of erythropoiesis stimulating agents.

OBJECTIVE: In 2011, the Centers for Medicare and Medicaid Services (CMS) replaced fee-for-service reimbursement for erythropoiesis stimulating agents (ESAs) with a fixed-sum bundled payment for all dialysis-related care and pay-for-performance incentives to discourage maintaining patients' hematocrits above 36 percent. We examined the impact of the new payment policy on the use of ESAs. DATA SOURCES: CMS's Renal Information Management System. STUDY DESIGN: Regression discontinuity design assessing the use of ESAs by hematocrit level before and after the implementation of the payment policy change. DATA EXTRACTION: Secondary data from 424,163 patients receiving hemodialysis treatment between January 2009 and June 2011. PRINCIPAL FINDINGS: The introduction of bundled payments with pay-for-performance initiatives was associated with an immediate and substantial decline in the use of ESAs among patients with hematocrit >36 percent and little change in the use of ESAs among patients with hematocrit ≤36 percent. In the first two quarters of 2011, the use of ESAs during dialysis fell by about 7-9 percentage points among patients with hematocrit levels >36 percent. No statistically significant differences in ESA use were observed at the thresholds of 30 or 33 percent. CONCLUSIONS: CMS's payment reform for dialysis care reduced the use of ESAs in patients who may not benefit from these agents.

Diabetes diagnosis and exercise initiation among older Americans.

OBJECTIVE: To determine whether exercise participation increased following a new diagnosis of diabetes using a sample of U.S. individuals aged 50 and over who did not report exercise prior to diagnosis. METHODS: We used data from the 2004-2010 Health and Retirement Study in a pre-post study design. Individuals newly-diagnosed with diabetes (N=635) were propensity score matched to a comparison group with no diabetes. RESULTS: In the year following a reported diagnosis, 35.7% (95% confidence interval 32.0 to 39.5) of those newly diagnosed with diabetes initiated exercise as compared with 31.4% (95% confidence interval 27.9 to 35.1) for the matched cohort with no diabetes, with a between-group difference of 4.3 percentage points (95% confidence interval -0.9 to 9.4). Among individuals with fewer health risk factors at baseline, the between-group difference was 15.6 percentage points (95% confidence interval 1.58 to 29.5). CONCLUSION: Over 35% of persons with a new diagnosis of diabetes initiated moderate or vigorous exercise in the year following their diagnosis. Among individuals with fewer health risk factors at baseline, those newly-diagnosed with diabetes were more likely to begin exercise than those without diabetes.

Different analyses estimate different parameters of the effect of erythropoietin stimulating agents on survival in end stage renal disease: a comparison of payment policy analysis, instrumental variables, and multiple imputation of potential outcomes.

OBJECTIVE: To compare the assumptions and estimands across three approaches to estimate the effect of erythropoietin-stimulating agents (ESAs) on mortality. STUDY DESIGN AND SETTING: Using data from the Renal Management Information System, we conducted two analyses using a change to bundled payment that, we hypothesized, mimicked random assignment to ESA (pre-post, difference-in-difference, and instrumental variable analyses). A third analysis was based on multiply imputing potential outcomes using propensity scores. RESULTS: There were 311,087 recipients of ESAs and 13,095 non-recipients. In the pre-post comparison, we identified no clear relationship between bundled payment (measured by calendar time) and the incidence of death within 6 months (risk difference -1.5%; 95% confidence interval [CI] -7.0%, 4.0%). In the instrumental variable analysis, the risk of mortality was similar among ESA recipients (risk difference -0.9%; 95% CI -2.1, 0.3). In the multiple imputation analysis, we observed a 4.2% (95% CI 3.4%, 4.9%) absolute reduction in mortality risk with the use of ESAs, but closer to the null for patients with baseline hematocrit level >36%. CONCLUSION: Methods emanating from different disciplines often rely on different assumptions but can be informative about a similar causal contrast. The implications of these distinct approaches are discussed.