Cost of Home Dialysis in France

Abstract

Summary

Medico-economic evaluation is defined as economic evaluation applied to the health field. It is a comparative analysis of different diagnostic, therapeutic or preventive strategies, based on their costs and health outcomes. We have only one medico-economic study on the costs of dialysis in France, carried out by the Haute Autorité de Santé, which covered the year 2012 and consisted of cross-referencing 3 databases: the Registre Réseau Épidémiologique et Information en Néphrologie and the Système National d’Informations Inter-régimes de l’Assurance Maladie et de l’Hospitalisation. Analyses focused on prevalent patients, incident patients and key patient characteristics: age, presence of diabetes and care trajectories. The average monthly cost varied considerably according to the management modality, from 3774 euros/month in autonomous continuous ambulatory peritoneal dialysis (CAPD) to 7253 euros/month in center-based hemodialysis. The monthly cost of therapies according to the patient profile appears to be strongly affected by the diabetic status of the patients. This analysis shows the high cost of transport for patients on in-center hemodialysis (20% of total expenditures), and even higher for nursing care in assisted CAPD (37% of total expenditures). The total tariff decreases from 2014 to 2020 were -17.6% for center-based hemodialysis and -9.8% for the low medicalized dialysis unit (LMDU), while the total 2014–2021 tariff increases were +9.3% for CAPD and +9.1% for automated peritoneal dialysis (APD). Paradoxically, these price changes have increased the cost of assisted peritoneal dialysis, which is now almost at the same level of overall cost as in-center hemodialysis for the French health insurance system. The ongoing study of the Physidia Laboratory’s retrospective cohort on daily home hemodialysis (DHH) should allow us to know the current cost of each hemodialysis technique currently practiced in France, including DHH.

1 - INTRODUCTION

Healthcare expenses reimbursed by the French health national insurance system called Assurance Maladie in France amounted to 167 billion euros in 2019 for all schemes; expenditures for the management of end-stage chronic renal failure amounted to 4.1 billion, or 2.45% of all expenditures for 98,427 patientsFigure 1;[1].

Figure 1.Distribution of health insurance expenses reimbursed in 2019 by category of pathologies, chronic treatments and episodes of care: 167 billion euros for all schemes

The annual expenditure per patient for end-stage chronic renal failure is the highest, regardless of the pathology, chronic treatment or episode of care, and amounts to an average of 41,701 euros/year/patient (Table I);[1].

Table I.Numbers and average expenditure cost per patient for each group of pathology or episode of care, in 2019 in France

Pathology, treatment or health event	Numbers	Total average cost	including  outpatient care	including hospitalizations	including cash services
Cardio-neurovascular diseases	5 129 236	3 448 €	1 542 €	1 740 €	215 €
Including acute cardio-neurovascular diseases	454 615	9 142 €	1 481 €	7 967 €	237 €
Including chronic cardio-neurovascular diseases	4 982 836	2 716 €	1 452 €	1 064 €	200 €
Treatment of vascular risk (independently of pathology)	8 476 179	661 €	508 €	47 €	106 €
Diabetes	3 964 561	2 164 €	1 810 €	211 €	143 €
Cancers	3 297 155	6 097 €	2 502 €	3 243 €	352 €
Including active cancers	1 467 392	12 270 €	4 661 €	7 091 €	518 €
Including cancers under medical supervision	1 930 730	1 086 €	730 €	149 €	207 €
Psychiatric deseases or psychotropic drugs	8 103 919	2 804 €	799 €	1 359 €	646 €
Including Psychiatric diseases	2 508 405	6 413 €	1 252 €	4 179 €	982 €
Including Psychotropic drugs	5 595 514	1 187 €	597 €	95 €	495 €
Neurological or degenerative diseases	1 673 904	4 576 €	2 879 €	1 341 €	355 €
Chronic respiratory diseases (excluding cystic fibrosis)	3 656 804	954 €	589 €	267 €	98 €
Inflammatory diseases, or rare diseases or HIV or AIDS	1 286 272	4 744 €	3 292 €	1 025 €	427 €
End-stage kidney disease	98 427	41 701 €	12 692 €	28 194 €	815 €
Including chronic dialysis	54 566	60 557 €	16 965 €	43 097 €	496 €
Including kidney transplantation	3 514	68 127 €	15 590 €	50 333 €	2 204 €
Including follow up of kidney transplantatioon	40 347	13 897 €	6 660 €	6 111 €	1 126 €
Diseases of the liver or pancreas (excluding cystic fibrosis)	604 162	2 545 €	1 391 €	913 €	241 €
Other long-term diseases	1 975 489	2 177 €	1 627 €	364 €	186 €
Pregnancy (with or without pathologies)	1 265 621	6 698 €	979 €	2 856 €	2 863 €
Occasional hospitalizations (with or without pathologies, treatments or maternity)	9 417 185	3 972 €	553 €	3 054 €	365 €
Analgesic or anti-inflammatory treatment (excluding pathologies, treatments, maternity or hospitalizations)	1 308 126	1 159 €	608 €	89 €	462 €
No pathology, treatment, maternity, hospitalization, or analgesic or anti-inflammatory treatment	36 194 044	308 €	196 €	32 €	79 €

Given the importance of such financial volumes, medico-economic analysis is of paramount importance. Medico-economic evaluation is defined as the economic evaluation applied to the field of health; it is a comparative analysis of the different diagnostic, therapeutic or preventive strategies on the basis of their costs and their health outcomes[2]. The use of medico-economic analysis has been imposed for 30 years by various French and European health agencies: the High Authority for Health (Haute autorité de Santé (HAS) and the National Health Security Agency of Food, Environment and Labor (Agence Nationale de sécurité Sanitaire de l’alimentation, de l’environnement et du travail (ANSES)) in France, The National Institute for Health and Care Excellence (NICE) in England, and the Institut für Qualität und Wirtschaftlichkeit im Gesundheitwesen (IQWiG) in Germany[2].

2 - HAS METHODOLOGY

The analytical methodology initially included the drafting of a framework note defining the feasibility and scope of the project, validated by the Commission for Economic and Public Health Assessment (Commission d’Évaluation Économique et de Santé Publique (CEESP)) of HAS on July 6, 2010 and secondarily validated by the College of HAS on November 3, 2010. A multidisciplinary and multiprofessional working group comprising health economists, methodologists, nephrologists (all types of practice), caregivers, administrators and representatives of associations of patients with renal insufficiency was then formed[3]. This working group met from February 2011 to June 2014, for a total of 7 working meetings[3]. The report drawn up by the working group was submitted to a multidisciplinary and multiprofessional review group[3]. The final report was approved by the Commission for Economic and Public Health Assessment (Commission d’Évaluation Économique et de Santé Publique (CEESP)) and then validated by the HAS board[3].

3 - MAIN RESULTS OF HAS WORK

3-1. What were the conclusions of the HAS concerning the data from the literature on medico-economic studies

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