The Impact of Recent Policy Changes on the Treatment of Patients with Kidney Disease in the U.S. Público

Abstract

In the United States, chronic kidney disease is a large, and growing public health concern that disproportionately affects minorities and individuals with low socioeconomic status. While Medicare covers patients who have progressed to end-stage renal disease, coverage prior to ESRD is critical to improving patient outcomes. Medicaid expansion has extended coverage to millions of Americans and presents a significant opportunity to improve the care of CKD patients. Guidelines for the care of these patients have changed over time and it is important to understand how insurance coverage interacts with such changes. Once patients progress to ESRD, the preferred treatment is a living donor kidney transplant. Both Medicaid expansion and the recently implemented Kidney Allocation System have potential to significantly alter access to living donor kidney transplantation. This dissertation seeks to illuminate the interactions between guidelines, changes in insurance coverage, and organ allocation policy, and how these factors impact care of patients with CKD. The three essays of my dissertation examine: the impact of Medicaid expansion and guideline changes on pre-ESRD nephrology care; the impact of Medicaid expansion on rates of living donor kidney transplantation; and the impact of Medicaid expansion and the new Kidney Allocation System on racial disparities in living donor kidney transplantation rates.  

The findings of this dissertation provide evidence that, although improving coverage for low socioeconomic status individuals is an important step towards improved access to care, it is not sufficient to ensure that all patients are receiving equitable treatment. Given the large downstream costs associated with poorly treated CKD, it is important that efforts are made to improve preventive care and to encourage living donation. The findings also suggest that improving access to deceased donor kidney transplantation for minorities may have inadvertently worked to funnel minorities to suboptimal care. Policies targeting patients with CKD need to be carefully considered within the framework of existing health care policy to ensure that as we increase access for vulnerable populations we do not further disadvantage them by discouraging them from seeking optimal treatment.

Table of Contents

CHAPTER 1: Introduction ...................................................................................... 1

       1.1 CKD and its Treatment ………………………………………………………………….1

           1.1.1 CKD and ESRD …………………………………………………………………….1

1.1.2 Living Donor Kidney Transplantation vs Deceased Donor Kidney Transplantation ..1

           1.1.3 Nephrologists and the Physician Shortage …………………………………….........2

1.2 Policy related to ESRD Care and ESRD Patients ……………………………………….3

1.2.1 The 2014 Kidney Allocation System ……………………………………………….3

1.2.2 The 2012 Kidney Disease Improving Global Outcomes Guidelines ……………….4

1.2.3 Medicaid and Medicare ……………………………………………………………..5

CHAPTER 2: The Impact of Medicaid Expansion on the Receipt of Pre-ESRD Nephrology Care ...11

2.1 Introduction .............................................................................................................................11

2.2 Data .........................................................................................................................................15

2.2.1 Study Variables.............................................................................................................16

2.2.2 Limitations .................................................................................................................. 17

2.3 Methods………………………………………………………………………………………18

           2.3.1 Medicaid Patients…………………………………………………………………..18

2.3.2 Full Sample…………………………………………………………………………...19

2.4 Results .....................................................................................................20

2.4.1 Medicaid……………………………………………………………………………...21

2.4.2 Full Sample…………………………………………………………………………...21

2.5 Discussion ...............................................................................................22

References .....................................................................................................27

CHAPTER 3: Variation in Living Donor Kidney Transplantation and the Impact of Medicaid Expansion ... 41

3.1 Introduction…..........................................................................................41

3.2 Methods ...................................................................................................44

3.2.1 Study Population and Data Source.........................................................44

3.2.2 Study Variables.......................................................................................45

3.2.3 Statistical Analysis ................................................................................46

3.3 Results ......................................................................................................47

3.4 Discussion ................................................................................................ 49

References ..................................................................................................... 60

CHAPTER 4: The interaction between the new Kidney Allocation System and Medicaid Expansion on Access to Living Donor Kidney Transplantation 62

4.1 Introduction .............................................................................................62 

4.2 Methods ...................................................................................................65

4.3 Results .....................................................................................................66

4.4 Discussion ................................................................................................68

References ......................................................................................................77

CHAPTER 5: Conclusions ...............................................................................83

5.1 CKD, ESRD, and Nephrology Care…………………………………………………. 83

5.2 Main Findings ……………………………………………………………………………83

5.2.1 The 2014 Kidney Allocation System ……………………………………………..83

5.2.2 The 2012 Kidney Disease Improving Global Outcomes Guidelines ………85

5.2.3 Medicaid Expansion ………………………………………………………………....86

5.3 Conclusions ………………………………………………………………………………87

References……………………………………………………………………………………89

About this Dissertation

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School	Laney Graduate School
Department	Health Services and Research Health Policy
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Medicine and Surgery Economics, General Health Sciences, Public Health
Palabra Clave	end-stage renal disease chronic kidney disease Kidney Allocation System Medicaid Expansion Transplantation nephrology
Committee Chair / Thesis Advisor	Hockenberry, Jason, Emory University
Committee Members	Howard, David, Emory University Patzer, Rachel, Emory University

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