Commercial Health Insurance and Quality of Care in US Dialysis Facilities.

Rationale & Objective: Commercial health insurance typically reimburses at a higher rate for dialysis than Medicare. A recent ruling by the US Supreme Court could result in many commercially insured patients who receive dialysis forgoing their private health insurance and shifting to Medicare as the primary payer. Our objective was to determine whether differences in commercial payers as a proportion of payer mix affect the quality of care at dialysis facilities. Study Design: Cross-sectional study. Setting & Population: We examined US patients receiving dialysis from US Dialysis Facility Reports and the Dialysis Facility Compare websites in 2019. Exposures: Percentage of prevalent dialysis patients with commercial health insurance. Outcomes: Seven key dialysis facility quality metrics included in Dialysis Facility Compare star ratings. Analytical Approach: Multivariable linear regression models adjusted for observed confounders. Results: Among 7,194 US dialysis facilities, an average of 4.4% of prevalent dialysis patients had commercial insurance. Each 10% absolute increase in the percentage of dialysis patients in a facility with commercial insurance was associated with an adjusted 8.3% (3.0%-13.6%) lower standardized mortality ratio. Commercial health insurance was not significantly associated with the remaining quality metrics examined, including standardized fistula rate, long-term catheter rate, standardized hospitalization ratio, standardized transfusion ratio, dialysis adequacy, and In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems patient experience score. Limitations: The potential for unobserved confounders including social risk factors limits the ability to make causal inferences. Conclusions and Relevance: Dialysis facilities with a higher percentage of patients with commercial health insurance had better performance in standardized mortality ratio. If this association reflects a causal connection, then increased shifting of coverage from commercial health insurance to Medicare could adversely affect the quality of care at dialysis facilities.