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Scheduled dialysis for undocumented immigrants saves money and lives

(Reuters Health) – Providing scheduled dialysis for undocumented immigrants with kidney failure, rather than offering them only emergency dialysis, dramatically reduces deaths, healthcare use and costs, a study in Texas suggests.

The difference was so significant that the study authors recommend scheduled, three-times-a-week dialysis as the universal standard of care for all patients in the U.S. with end-stage renal disease (ESRD).

“Undocumented immigrants are working and contributing members of our communities who came to the U.S. to work and support their families, and they typically don’t know they have kidney problems until a health crisis arises,” said Dr. Oanh Nguyen of the University of California, San Francisco.

In 40 states, scheduled dialysis is denied to undocumented immigrants with ESRD because they are not eligible for Medicare and Medicaid government insurance. Instead, they receive dialysis through the emergency department only when their symptoms become life-threatening, the study team writes in JAMA Internal Medicine.

“This is the most expensive and least patient-centered way to help,” Nguyen said in a phone interview. “There must be a better option than this terrible status quo.”

Nguyen and colleagues took advantage of a unique situation in 2015, when undocumented adults with ESRD in Dallas became eligible for private insurance. Among 181 patients with ESRD, 105 received the coverage and started getting regular scheduled dialysis while 76 patients did not qualify for the coverage and continued getting emergency-only dialysis.

Most of the patients had medical records at Parkland Hospital for six or more years before the study period, suggesting they were long-standing Dallas residents, the study team notes.

The authors looked at data from Parkland as well as emergency department and hospital claims from 80 hospitals within 100 miles of Dallas and 30 dialysis centers, covering the period starting six months before the private insurance became available and continuing for 12 months after enrollment.

With scheduled dialysis instead of emergency dialysis, annual rates of death fell from 17 percent to 3 percent. Patients getting scheduled treatments also averaged six fewer emergency department visits and 1.5 fewer hospitalizations every month. They also spent 10 fewer days in the hospital in each six-month period.

As a result, those getting scheduled dialysis incurred $5,648 less in healthcare costs each month compared with those getting emergency-only dialysis, for an annual savings of nearly $70,000 per patient getting scheduled dialysis.

“We were most surprised by how immediate and dramatic the benefits were, and the cost savings were huge,” Nguyen said. “Scheduled dialysis is one of the most expensive therapies, but as it turns out, emergency-only dialysis is even more costly.”

From a kidney specialist’s standpoint, the findings are not surprising, said Dr. Rudolph Rodriguez of the University of Washington in Seattle, who wasn’t involved in the study.

“The question anyone should ask is, ‘Why would local, state or federal governments allow a treatment to continue that leads to higher death rates and higher costs?’” he said in an email. “Politics are part of the answer, but also the fact that the savings discussed in the study are not realized by one entity.”

Instead, federal, state and local hospital dollars share costs for dialysis treatment and emergency department services, Rodriguez explained. Providing scheduled dialysis for undocumented immigrants would require a patchwork of solutions, such as states bearing the cost or a medical center partnering with a charitable assistance program.

“Given the collective research on this issue, there’s enough evidence to suggest that providing access to care for this community makes sense, whichever perspective you come from,” said Lilia Cervantes of Denver Health and Hospital Authority in Colorado, who also wasn’t involved in the study.

“The perspective that often speaks to us in this country is that scheduled dialysis is a more fiscally responsible way to provide care,” she said in a phone interview. “At the end of the day, we’re all human beings who want to work, have families and be healthy.”

SOURCE: and JAMA Internal Medicine, online December 21, 2018.

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