The incidence of end-stage renal disease (ESRD) in China is currently estimated to be 102 cases per million of the population. The prevalence is projected to rise rapidly, fueled by the aging of the population and the high prevalence of related primary chronic disease.1 Fifty-five percent of ESRD patients are currently receiving hemodialysis or continuous ambulatory peritoneal dialysis (CAPD). The two-year, three-year and five-year survival rates for dialysis patients are 50%, 40% and 20% respectively; a small number of patients survive for more than ten years. The financial support for dialysis comes mainly from government sources. Government employees, those who work for government owned enterprises and those who can access to governmental medical insurance program are able to gain a part or full of reimbursement for the costs of their treatment.1 Nonetheless, a great number of people can not gain reimbursement for their treatment or can not afford the remaining expense after the reimbursement. The main reason for non-acceptance onto dialysis programs is the great cost.1 In the United States, the expenditure for dialysis is about 5% of the overall health expenditure of the society but serves only 0.7% of overall patients. In Europe, the proportion of total health expenditure absorbed by renal replacement therapy vary from 0.7% in the United Kingdom to 1.8% in Belgium, whereas the proportion with ESRD is only 0.022% to 0.040% of the total population.2 The objective of healthcare systems is to provide an optimal mix of access, quality and cost. The rapidly increasing number of patients with ESRD makes the expenditure on dialysis become an important social problem.3,4 Dialysis care is supported by public providers in Canada5,6 and the UK;7 by both public and private insurance in Germany8 and Japan9 and by private insurance in US.10,11 Because of the variety of healthcare systems, the funding and reimbursement are different from country to country.12–17 Countries whose dialysis care is supported by public providers have lower prevalence rates of ESRD and lower treatment rates than other countries.18 This may be due to the differences in the healthcare systems themselves and, at least in part, by the lack of private interest and investment in ‘public’ countries.19 In order to use their limited resources more efficiently, a number of governments are discussing and introducing new reimbursement policies, various alternatives are considered.20 In the present study we design an auxiliary business insurance program to provide one possible solution of alleviating the economic burden of Chinese peritoneal dialysis (PD) patients.
All patients who started PD treatment as the first renal replacement therapy from August 1992 to September 2005 in the PD centers of the First and the Third Teaching Hospitals of Peking University, Beijing and who survived the first 3 months of dialysis, were included in this study. A total of 641 peritoneal dialysis patients were eligible for this study.
Data were obtained from the clinical data system in the two PD centers retrospectively. A chronic disease management system was implemented to follow up patients in the two centers. Survival data of all 641 patients were collected, including the length of period on PD and the outcome of the patients. The end-points of survival analysis were death, transfer to hemodialysis (HD), renal transplantation or PD at December 31, 2005. The time of transfer to HD or renal transplantation and December 31, 2005 (if PD) were regarded as right censoring. The data on the amounts (bags) of dialysate consumed each day were searched from the case history of 641 PD patients, of whom 370 had complete records. Data on the length of the period from the onset of PD-related primary disease (chronic nephritis, diabetes mellitus, hyperpietic) to the beginning of PD were searched from the case histories of 328 PD patients in the PD center of the Third Teaching Hospital; of whom 288 had complete records.
An auxiliary business insurance program for PD patients
An auxiliary business insurance program was designed to finance the potential patients of end stage renal disease for PD therapy for cost besides the possible reimbursement. Patients with PD-related primary diseases (chronic nephritis, diabetes mellitus and hyperpietic) who are at risk of developing end-stage renal disease are supposed to purchase this auxiliary business insurance at the onset of these diseases and the premium should be paid yearly from onset of the primary disease until death. Claims can be asked for by the insurants when they progress to ESRD and start PD; and can also be asked for by the insurants when they switch to HD or renal transplantation, as if they were still on PD, until the sum of claims reaches the total premium being submitted. Since the length of time from onset of primary disease to beginning of PD of 6 of 288 patients (2%) being over 30 years in our data set, it is suggested that the insurant are allowed quitting the program and getting their entire submitted premium back including interest if they do not progress to ESRD in 30 years.
Estimation of the expenses on PD therapy
Collective risk model21,22 was employed to estimate the expenses on PD therapy. Let E denote the mean of expenses on PD from beginning of PD to death; B denote the mean of amounts (bags) of dialysate consumed each day by PD patients; m denote the mean survival time (month) counted from beginning of PD; A denote the unit price for each bag of dialysate. The expense on PD for an ESRD patient was estimated by
Estimation of the probability of ESRD progressing from a primary disease
Let P denote the prevalence rate of a given primary disease, F denote the percentage of ESRD patients with this primary disease, Pe denote the prevalence rate of ESRD, and Q denote the probability of a patient progressing to ESRD from this primary disease, Then Q is estimated by
Determination of pure premium
The annuity method23 was employed to determine the pure premium. The premium was paid yearly from onset of a PD-related primary disease. Let n denote the length (year) of period from onset of a primary disease through ESRD to death on PD and i denote the interest rate. For one who paid the pure premium by C0 yearly, the accumulation of n years' pure premium would be equal to
Suppose one was destined to be an ESRD patient, the pure premium would be the solution of the equation T=E, then he or she should pay
For any individual who may process to ESRD with a probability Q, the pure premium he or she should pay would be
If the percent of expenses on PD therapy reimbursed by an existing insurance was k, then the right side of formula (5) would add one more factor (1-k) so that the pure premium would be (1-k)QC0.
Statistical analysis was performed by the statistical software SPSS, version 13.0 (SPSS Inc, Chicago, IL). The Kaplan-Meier method was employed to estimate the survival curves and obtain mean survival time. The log-rank test was used to compare the survival curves between subgroups. Continuous variables were expressed as mean ± standard deviation (SD); the mean survival time and mean length of disease were expressed as mean ± standard error (SE); whereas categorical variables were expressed as percentage or ratio. Comparison among independent groups was analyzed by means of t test, Chi-square test or ANOVA. All tests were 2-sided. The test was considered to be statistically significant if P <0.05.
The mean age of 641 PD patients was (63±14) years old; 47.1% of PD patients were male; 45.4% of PD patients had chronic nephritis as primary disease, 26.7% had diabetes mellitus, 17.5% had hyperpietic and 10.5% had others (polycystic kidney, myeloma, acute renal failure or unknown etc.). Baseline information is shown in Table 1. There were significant differences in the distributions of age and gender among PD patients with three different primary diseases (P=0.000 respectively).
The mean survival times of PD patients were (46.6±3.4) months for male, (53.5±3.2) months for female (not significantly different, P=0.143); (52.0±4.5) months for age 60 and below, (50.0±2.7) months for age beyond 60 (not significantly different, P=0.274); (52.0±3.5) months for the First Hospital, (49.5±3.2) months for the Third Hospital (not significantly different, P=0.620); (55.1±3.7) months for primary disease of chronic nephritis, (38.9±3.2) months for diabetes mellitus, (61.4±4.6) months for hyperpietic (significantly different, P=0.000). The survival curves of PD patients who had different primary diseases are shown in Figure. There was no significant difference between the survival curves of different age groups (60 below and beyond 60) with the same primary disease (P=0.368, 0.216, 0.558 for chronic nephritis, diabetes mellitus and hyperpietic respectively). The mean survival times from the beginning of PD to death were obtained from survival analysis:
where subscripts C, D and H represent the primary diseases chronic nephritis, diabetes mellitus and hyperpietic, respectively.
Expenses on PD therapy
The amount (bags) of dialysate consumed each day by PD patients ranged from 1 to 6, and there was no significant difference in mean amount among different primary diseases (P=0.081). The survival curves of patients who consumed different bags of dialysate each day were compared, and there was no significant difference (P=0.808). The mean amounts (bags) of dialysate consumed each day by PD patients who had different primary diseases were
The unit price of each bag of dialysate was assumed as RMB 43 Yuan. The mean expenses (Yuan) of patients with different primary diseases on PD from beginning of PD to death were
The mean length of the period from onset of primary disease to beginning of PD was (19±1) years for chronic nephritis, (15±1) years for diabetes mellitus, and (20±1) years for hyperpietic, respectively (significantly different, P=0.002). Then the mean survival times (years) from onset of primary disease to death on PD were
Based on our data of 641 PD patients the percentages of ESRD patients with primary diseases chronic nephritis, diabetes mellitus and hyperpietic were
According to the latest literatures,24–26 the prevalence rates of chronic nephritis, diabetes mellitus, hyperpietic and ESRD were estimated respectively by
The probabilities Qc, Qd and Qh were estimated by equation (2):
The interest rate was assumed as 4%. By formulae (1) and (4),
and by formula (5), the pure premiums (Yuan/year) for any individual patient with primary diseases chronic nephritis, diabetes mellitus and hyperpietic were
All of the above results are summarized in Table 2.
Our study designed an auxiliary business insurance program in order to help the potential end stage renal disease patients finance their possible PD therapy in the future. The pure premiums for the patients with PD related primary diseases, chronic nephritis, diabetes mellitus, and hyperpietic, had been estimated. However, as a whole business insurance plan there were many other aspects that need to be considered, such as additional premiums, ruin probability and reserve for coping with business expenditure and accidental risks.
If every one were destined to process to ESRD from their primary disease, the pure premiums should be 6196, 6596 and 6422 (Yuan/year) for the primary diseases chronic nephritis, diabetes mellitus and hyperpietic respectively. They were not quite different, but really high indeed. However, since the probabilities Qc, Qd and Qh are low, the high expenditure will be shared by all the patients with chronic nephritis, diabetes mellitus and hyperpietic so that the pure premiums for any individual patient of chronic nephritis, diabetes mellitus and hyperpietic will be 35.94, 87.73 and 7.71 Yuan/year respectively, which is very low. Furthermore, if one already has medical insurance, the available reimbursement rate is k, then the pure premiums for this auxiliary insurance would be timed by (1-k), and be much lower. All of these factors make this program feasible in practice.
Our results were mainly based on the data of two PD centers within the First and the Third Teaching Hospitals of Peking University; where the patients had received superior PD therapy and achieved longer survival due to the high level technology and management. Therefore, the estimated pure premiums were higher than what they ought to be. In practice, they could be referenced as upper limits.
The proposal in this paper is just one of the possible solutions for the funding of PD therapy; the authors have also been working on other proposals and would like to share with the readers elsewhere. According to the Chinese saying, it is to throw out a brick to attract a jade. We wish more attention would be paid by both governmental and commercial insurance to such issues related to medical equity.
1. Lin SY. Nephrology in China: A great mission and momentous challenge. Kidney Int 2003; 83: 108–110.
2. Arrigo S, Giuseppe R. Chronic renal disease as a public health problem: epidemiology, social, and economic implications. Kidney Int 2005; 68: 7–10.
3. Straube BM. The imperatives for change in the US health care payment and delivery systems are clear. Adv Chronic Kidney Dis 2008; 15: 7–9.
4. Dor A, Pauly M, Eichleay M. End-stage renal disease and economic incentives: the international study of health care organization and financing. Int J Health Care Finance Econ 2007; 7: 73–111.
5. Manns B, Mendelssohn D, Taub K. The economics of end-stage renal disease care in Canada: incentives and impact on delivery of care. Int J Health Care Finance Econ 2007; 7: 149–169.
6. Zelmer JL. The economic burden of end-stage renal disease in Canada. Kidney Int 2007; 72: 1122–1129.
7. Roderick P, Nicholson T, Armitage A, Mehta R. An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite unites in England and Wales. Health Technol Assess 2005; 9: 171–178.
8. Kleophas W, Reichel H. International study of health care organization and financing: development of renal replacement therapy in Germany. Int J Health Care Finance Econ 2007; 7: 185–200.
9. Naito H. The Japanese health-care system and reimbursement for dialysis. Perit Dial Int 2006; 26: 155–161.
10. Derrick FW, Scott CE. National health insurance: lessons from the United States experiment. Health Care Management Rev 1995; 20: 55–63
11. Ray NF, Ross M. Challenges and directions for Medicare ESRD payment policy. Semin Nephrol 2000; 20: 565–576.
12. Harris A. The organization and funding of the treatment of end-stage renal disease in Australia. Int J Health Care Finance Econ 2007; 7: 113–132.
13. Durand-Zaleski I, Combe C. International study of health care organization and financing for end-stage renal disease in France. Int J Health Care Finance Econ 2007; 7: 171–183.
14. Pontoriero G, Pozzoni P, Vecchio L, Locatelli F. International study of health care organization and financing for renal replacement therapy in Italy: an evolving reality. Int J Health Care Finance Econ 2007; 7: 201–215.
15. Ashton T, Marshall M. The organization and financing of dialysis and kidney transplantation services in New Zealand. Int J Health Care Finance Econ 2007; 7: 233–252.
16. Biesen W, Lameire N, Peeters P, Vanholder R. Belgium's mixed private/public health care system and its impact on the cost of end-stage renal disease. Int J Health Care Finance Econ 2007; 7: 133–148.
17. Wikstrom B, Fored M, Eichleay M, Jacobson S. The financing and organization of medical care for patients with end-stage renal disease in Sweden. Int J Health Care Finance Econ 2007; 7: 269–281.
18. Horl WH, De Alvaro F, Williams PF. Healthcare systems and end-stage renal disease (ESRD) therapies — an international review: access to ESRD treatments. Nephrol Dial Transplant 1999; 14: 10–15.
19. Hidai H. Need for an incentive-based reimbursement policy toward quality care for dialysis patient management. Kidney Int 2000; 58: 363–373.
20. De Vecchi AF, Dratwa M, Wiedemann ME. Healthcare systems and end-stage renal disease (ESRD) therapies — an international review: costs and reimbursement/funding of ESRD therapies. Nephrol Dial Transplant 1999; 14: 31–41.
21. Dickson DC. Insurance risk and ruin. Cambridge: Cambridge University Press; 2005: 52–89.
22. Panjer HH, Willmot GE. Insurance risk models. Illinois: Society of Actuaries; 1992: 19–36.
23. Liu ZG. Interest theory. Nankai University Press; 2000: 41–50.
24. Chen W, Wang H, Chen WQ, Yu XQ. The study on the epidemiology of chronic kidney disease in Guangzhou citizens. Chin J Nephrol (Chin) 2007; 23: 147–151
25. Li LM, Rao KQ. A description on the Chinese national nutrition and health survey in 2002. Chin J Epidemiol (Chin) 2005; 26: 478–484.
26. Liu XX, Zhang H. The conception and objective in prevention and treatment of chronic kidney disease. Practical Prev Med (Chin) 2007; 14: 229–231.