Dialysis Care | March 2023

Dialysis Care

Dialysis care provides a function that failing kidneys no longer provide to the body. In short, dialysis removes toxins from the blood when the kidneys cannot. Depending on the level and nature of kidney impairment, and overall health of the patient, several options exist. Acute kidney failure may require short-term dialysis treatment, whereas chronic disease typically requires dialysis treatment for the remainder of life (or transplant).

There are two main methods of dialysis care: peritoneal or hemodialysis. In hemodialysis, blood is pumped out of the body to an artificial kidney machine and returned to the body by tubes that connect the patient to the machine. In peritoneal dialysis, the inside lining of the patient’s own belly acts as a natural filter. Wastes are taken out by means of a cleansing fluid called dialysate, which is washed in and out of the belly in cycles. A dialyzer serves as an artificial kidney in most cases, filtering either the blood or fluid.

Dialysis most often occurs in an outpatient setting or at home but can also be provided in a hospital setting. Home dialysis is on the uptrend with companies helping patients get set up with a regimen and machine, if applicable.

Market Outlook: Growth
According to the Centers for Disease Control and Prevention, chronic kidney disease (CKD) affects more than 1 in 7 U.S. adults—an estimated 37 million Americans. For Americans with diabetes or high blood pressure—the two most common causes of kidney disease—the risk for CKD is even greater. Nearly 1 in 3 people with diabetes and 1 in 5 people with high blood pressure have kidney disease. Other risk factors for developing kidney disease include heart disease and a family history of kidney failure.

The U.S. dialysis centers market size was valued at $26.9 billion in 2022 and is expected to expand at a compound annual growth rate of 5.29% from 2023 to 2030. Major factors driving the growth of the market in the country are the high prevalence of renal diseases, technological advancements, favorable reimbursement, and the lack of kidney donors.

Facility Types & Key Players
The facility types are categorized as in-center, in-home, and skilled nursing facilities (SNF)-based. In 2022, the in-center segment had the highest revenue share owing to the high adoption of the service. Certain service providers such as DaVita, Inc., contract with a group or individual nephrologists to provide care at their facilities. However, the accessibility to centers varies state-wise. Missouri, South Dakota, Alabama, and Kentucky are among the states having a high number of outpatient facilities, accounting for 13 to 17 facilities per 1000 patients per the CDC. This is resulting in higher growth opportunities for the segment in these states.

SNF-based types are expected to have lucrative growth during the forecast period. According to NxStage, 65,000 Americans in these facilities require dialysis. The growing geriatric population in the U.S. requiring skilled nursing services are increasing the opportunities for such services. The SNFs are collaborating with dialysis centers to facilitate services. For instance, in August 2022, Infinite Care collaborated with Dialyze Direct for facilitating dialysis services at the SNF. The collaboration will enable the company to provide dialysis services in more than 170 facilities in the U.S.

The kidney dialysis business is highly concentrated, with the four largest competitors—Fresenius Medical Care, DaVita, U.S. Renal Care, and American Renal Associates—comprising more than 85% of the market, but substantial competition still takes place.

Potential Claims
Adverse events in dialysis centers may result in patient injury and lead to compensation claims. Among the most common events:

• Patient falls
• Negligent care and treatment
• Infection
• Improper sterilization, cleaning
• Failure to monitor or respond to changes in patient condition
• Negligent employment and supervision
• Dialyzer machine issues
• Medication errors

Underwriting Considerations
ProAssurance Miscellaneous Medical is part of our Specialty Underwriting division, which provides coverage on an excess and surplus basis. We can provide customized risk management solutions and liability insurance products and services depending on the modality/setting and method of dialysis care.

Rating is typically based on revenue or visits, the type of organization—for profit or nonprofit—as well as the size of operations. We also consider historical loss history and exposure growth.

Resources
National Kidney Foundation
National Institute of Diabetes and Digestive and Kidney Diseases
CDC: Chronic Kidney Disease Initiative

Submissions
MiscMedSubs@ProAssurance.com