Public payment for dialysis treatment has changed the rural health care marketplace

One of the chronically medically underserved populations in rural America, African American residents, on average live closer to dialysis facilities than white residents do.
Shanel Kilacharan | Flickr

Rural residents as a group live farther from dialysis treatment facilities than their urban counterparts. Given that rural America generally scores lower on health care access, that’s not a surprise.

But there is some unexpected news in a new study of dialysis access. One of the chronically medically underserved populations in rural America, African American residents, on average live closer to dialysis facilities than white residents do.

Jan Probst, a researcher at the Rural and Minority Health Research Center in South Carolina, has spent a career in medicine. She says she remembers being part of medical boards that decided who got certain treatments like dialysis and who didn’t. Her latest research looked at where dialysis centers are located and who lives in those areas, then compares the findings to similar past studies.

Dialysis is used to clean the blood when kidneys fail, also known as end stage renal disease. Those failures can be caused by diabetes and high blood pressure, among other things. Patients come to dialysis facilities and spend hours hooked up to machines that remove the blood from their body, filters it through an artificial kidney, and returns it to the body.

In her latest study, Probst looked at who lived in the areas around dialysis centers. What she found was that rural residents have to travel farther to get to dialysis treatment facilities.

This isn’t unexpected, she said. In the rural Southeast and Southwest, greater distances between communities mean those residents have to travel farther to get to their treatments. Rural residents, on average, have to travel just over 14 miles to get to the nearest facility. In contrast, urban residents live about 4.5 miles from the nearest dialysis center.

That’s a vast improvement from the last time Probst did the same research in 2013. In that study, rural residents in general had to travel about 40 miles to get to a dialysis facility.

But, the research found, one group, rural African Americans, was closer to dialysis facilities than any other racial group. On average, rural African Americans were only about 10.5 miles from a dialysis facility, while rural white residents were about 16.6 miles away. The study found that nearly three quarters (70%) of rural African American residents live within 15 miles from a facility, while less than half of white residents do. Only 42% of rural Hispanic residents and 39% of rural American Indians or Native Alaskans live within 15 miles of a dialysis facilities.

Funding changes improve access

The increase in access to dialysis centers isn’t solely due to need, Probst said. Since her 2013 study, how dialysis is funded has changed. Now, federal policy requires Medicare and Medicaid to pay for dialysis treatments. And once Medicaid and Medicare guaranteed payment, Probst said, the market responded, shifting most dialysis care to for-profit chains who entered areas knowing they were going to get paid. So, for-profit dialysis treatment facilities started popping up in areas with higher concentrations of patients who need the services.

Dialysis is expensive, Probst said. At current levels, dialysis and treating ESRD takes up about 7% of the Medicare budget, she said. Even for people who are insured, if a patient or their spouse has a sufficient work history, Medicare covers dialysis (or a kidney transplant) starting the fourth month of treatment.

So, providers put dialysis facilities in areas with higher concentrations of patients, she said. But, because these areas also tend to have limited access to other health services, which affects their ability to manage the illnesses that can lead to ESRD like diabetes, they are more likely to need dialysis. Lacking care for diabetes, she said, is a reason many rural African American residents develop end-stage renal disease.

Barriers remain

Still, even with dialysis centers closer to rural residents than they were in the past, there are barriers to care that may prevent patients from gaining access to the treatment they need.

“Dialysis is three times a week, and you have to sit there for like three hours,” she said. “That is a big time commitment for the persons or for their family members who are driving them.”

Additionally, dialysis facilities usually don’t have evening and weekend hours, increasing the amount of time taken off work for patients and their care providers. The burden dialysis places on rural patients would make maintaining any kind of job extremely difficult, she said.

“I suspect that for most of these folks that is not feasible, and they probably also have multiple things to deal with,” she said. “They’ve lost their kidneys, but they still have to deal with their dialysis. There’s a lot going on.”