Is it so small a thing To have enjoy d the sun, To have lived light in the spring, To have loved, to have thought, to have done e133

chapter NINE costs of chronic kidney disease Is it so small a thing To have enjoy d the sun, To have lived light in the spring, To have loved, to have thought, to have done Matthew Arnold, From the Hymn of Empedocles e133

1 usrds annual data report volume one ckd e13 Determining the economic impact of CKD on the healthcare system is challenging on several levels. The case definition is dependent on reported data. A biochemi- tative, but health plan datasets rarely con- costs of chronic kidney disease 9 introduction tain this information on a large scale. A definition of the CKD cohort using diagnosis codes, however, may represent only the more advanced and thus most expensive cases. In addition, CKD is a highly interactive disease, associated with cardiovascular disease (CVD), diabetes, stroke, and infectious complications. Given these limitations, we have developed a method using diagnosis codes to create a point prevalent CKD cohort. In the 9 ADR, new CKD patients were included in an attempt to produce a period prevalent cohort parallel to that created for the ESRD population. These patients, however, accounted for a disproportionate percentage of overall costs which could not be directly attributed to their CKD status. The reasons for this are numerous, but may include a high rate of acute kidney injury. This year we include only those patients classified as having CKD on January 1 of a given year, resulting in a true point prevalent cohort. When compared to last year s ADR, costs reported here for CKD patients are thus significantly lower, while those for non-ckd patients are higher. It is unclear which methodology most accurately depicts true CKD costs. Each has its strengths and weaknesses, and the differences seen with each method reflect the uncertainty involved in using claims to classify CKD. We begin by comparing data from Medicare and the Taiwan Bureau of National Health Insurance, which both use the Medicare billing format, thus allowing for precise comparisons between the two countries. Diabetes is diagnosed in and 18 percent of Medicare and Taiwanese patients, respectively, and CVD in 1 and 3 percent. (It is important to note that CVD in Taiwan is dominated by strokes, rather than the ischemic heart disease and congestive heart failure predominant in the U.S.) The CKD population recognized from diagnosis codes is also quite similar, at.8 and. percent. As mentioned elsewhere in the ADR, however, these numbers under-represent the total burden of CKD in older patients, suggesting that more advanced disease is being reported. The percentage of healthcare expenditures associated with CKD reaches 1 in the U.S., and in Taiwan, illustrating the significant financial impact of the disease. We next compare costs in the Medicare and younger employer group health plan populations, showing that overall costs per year reach $, and nearly $17,, respectively. Yearly costs for whites and African Americans with an additional diagnosis of diabetes or CHF reach $,, and $9, 3,.

Costs during the transition to ESRD are considerable, with the most striking occurring in the month of dialysis initiation at nearly $1, for Medicare patients, and $3, in the EGHP population. And expenditures per person per month in the first six months on dialysis are two times higher for EGHP patients than for Medicare patients, which may reflect pricing issues. Medicare sets prices for dialysis procedures and ancillary services, while private health plans, with few providers and only 1 percent of treated patients, have little leverage to negotiate pricing. Patients with commercial coverage can thus generate considerably more margin for dialysis providers, offsetting costs of the Medicare population or increasing profits for the large commercial dialysis chains. We introduce this year data from the Medicare Part D benefit, begun in. Medication costs for patients with CKD, diabetes, and congestive heart failure combined reach $,9 per year. We conclude by further examining costs in the U.S. and Taiwan. In both populations, CKD is highly interactive with diabetes and CVD. Expenditures as individuals transition from CKD to ESRD are also similar, starting relatively low and then rising rapidly. These findings suggest that cost patterns for CKD in other high-income countries may be similar as well, and provide evidence that CKD patients have a significant impact on a nation s healthcare costs. In prior editions of the ADR we have illustrated that preventive care is at less than recommended levels in both the U.S. and Taiwan. This area clearly needs to be addressed, as inadequate blood pressure, lipid, and glycemic control may contribute to progressive kidney disease and thus to a greater number of individuals reaching ESRD. see 17 for analytical methods. Point prevalent general (fee-forservice) Medicare patients, & point prevalent patients from the 1 percent Taiwan National Health Insurance sample, age & older, without ESRD. Diabetes, CVD, & CKD determined from claims; costs are for calendar year 8. 9 1i Distribution of costs of point prevalent general (fee-for-service) Medicare & Taiwanese patients with diagnosed CKD, cardiovascular disease, & diabetes General Medicare, age +: population, 8 (n = 3,93,; mean age 7.) Diabetes.% CKD.8% Taiwan National Health Insurance, age +: population, 8 (n = 1,788; mean age 7.9) CKD.% Diabetes 18.% CVD.% Diabetes 31.% CVD 3.% Diabetes 3.8% General Medicare, age +: costs, 8 ($3 billion) CKD 1.3% CVD 1.8% Taiwan National Health Insurance, age +: costs, 8 ($1.7 billion) CKD 11.8% overall costs of chronic kidney disease 13 components of costs for ckd 138 overview of medicare part d costs 1 ckd costs in the united states & taiwan 1 CVD 1% e13

Overall per person per year (PPPY) costs in 8 reached $19,7 for Medicare CKD patients, and $1,738 for those in the MarketScan database. Compared to those of patients with CKD of Stages 1, costs for those with Stage 3 CKD were 1. percent greater in the Medicare population, and. percent higher among MarketScan patients. In the Medicare population with both CKD and diabetes, PPPY costs for African American patients reached $,3 in 8, nearly 17 percent higher than the $1,7 for whites. Costs for those with Stage 3 CKD were 9.9 percent greater for African Americans, and 11. percent higher for white patients, than costs for their counterparts in the earlier stages of the disease. Costs for African American Medicare patients with both CKD and congestive heart failure were 1. percent higher in 8 than those for white patients with both diagnoses, at $3,9 compared to $8,89. Compared to those of patients in the earlier stages of CKD, costs for those with Stage 3 CKD were just. percent higher among whites, and nearly equal among African Americans. see 17 for analytical methods. Point prevalent Medicare patients age & older (9. ), & point prevalent MarketScan patients age (9.). 9 i PPPY costs ($, in thousands) Medicare (+) 1 1 MarketScan (-) 7 8 1 1 Overall PPPY costs in CKD patients, by CKD diagnosis code, dataset, & year All CKD 8.1-8.3-8.9/other 9 3i PPPY costs in Medicare CKD patients with diabetes, by CKD diagnosis code, race, & year 9 i PPPY costs in Medicare CKD patients with CHF, by CKD diagnosis code, race, & year 3 White 7 8 White 3 7 8 PPPY costs ($, in thousands) 1 African American 3 PPPY costs ($, in thousands) 1 African American 3 1 usrds annual data report volume one ckd e13 1 All CKD 8.1-8.3-8.9/other costs of chronic kidney disease 9overall costs of chronic kidney disease 1 All CKD 8.1-8.3-8.9/other

pppm expenditures during the transition to esrd 9 i PPPM expenditures ($, in 1,s) 9 7i PPPM expenditures ($, in 1,s) 3 3 1 1 8 Overall PPPM costs during the transition to ESRD, by dataset, 7 Medicare (age 7+) MarketScan (age <) - - - -3 - -1 1 3 Months pre- & post-initiation PPPM cardiovascular hosp. costs during the transition to ESRD, by dataset, 7 Medicare (age 7+) MarketScan (age <) - - - -3 - -1 1 3 Months pre- & post-initiation ICD-9-CM codes 8.1 Chronic kidney disease, Stage 1 8. Chronic kidney disease, Stage (mild) 8.3 Chronic kidney disease, Stage 3 (moderate) 8. Chronic kidney disease, Stage (severe) 8. Chronic kidney disease, Stage (excludes 8.: Stage, requiring chronic dialysis.^) 8.9/oth. ^ In USRDS analyses, patients with ICD-9-CM code 8. are considered to have code 8.; see Appendix A for details. CKD stage estimates are from a single measurement. For clinical case definition, abnormalities should be present 3 months. 9 i PPPM expenditures ($, in 1,s) 9 8i PPPM expenditures ($, in 1,s) 1 1 3 1 PPPM inpatient costs during the transition to ESRD, by dataset, 7 Medicare (age 7+) MarketScan (age <) - - - -3 - -1 1 3 Months pre- & post-initiation PPPM infectious hosp. costs during the transition to ESRD, by dataset, 7 Medicare (age 7+) MarketScan (age <) - - - -3 - -1 1 3 Months pre- & post-initiation Total per person per month (PPPM) costs in the month following ESRD initiation reached nearly $1, for Medicare patients in 7, and $31,9 for those in the MarketScan program.1 times greater. Inpatient costs during this month were.3 times greater for MarketScan patients, at $,81 compared to $9,8. In the months following initiation, overall costs are twice as high in the MarketScan population, while inpatient costs are nearly equal, suggesting a greater use of outpatient services among MarketScan patients. PPPM costs for cardiovascular hospitalizations in the month following initiation reach $3,39 and $7,7 for Medicare and MarketScan patients, respectively, while costs for hospitalizations related to infection reach $1,7 and $,3 (the difference in this latter number compared to data reported in the 9 ADR can be attributed to several hospitalizations with larger than average costs). see 17 for analytical methods. Incident Medicare (age 7 & older) & MarketScan (younger than ) ESRD patients, 7. e137

9 ai PPPM inpatient/outpatient & physician/supplier net costs ($) for CKD, by CKD diagnosis code, 8 1 usrds annual data report volume one ckd e Per person per month (PPPm) net costs are generally higher for Medicare patients with CKD of Stages 3 than for those with Stage 1 CKD. Total inpatient/outpatient costs in 8, for example, reached nearly $1,19 for those in the later stages of CKD, 1.8 percent higher than the $1,18 incurred by patients in the early stages. Outpatient costs for EPO were.3 times greater for later-stage CKD, and costs for skilled nursing, home health, and hospice were 13., 11., and. percent higher, respectively. Physician/supplier costs in 8 totaled $ for patients with Stage 3 CKD, 7.9 percent higher than the $ for patients with Stage 1. Prescription medications accounted for 11.9 and.8 percent of these total costs, respectively. see 173 for analytical methods. Point prevalent Medicare patients age & older, 8. ICD-9-CM codes 8.1 Chronic kidney disease, Stage 1 8. Chronic kidney disease, Stage (mild) 8.3 Chronic kidney disease, Stage 3 (moderate) 8. Chronic kidney disease, Stage (severe) 8. Chronic kidney disease, Stage (excludes 8.: Stage, requiring chronic dialysis.^) 8.9/oth. ^ In USRDS analyses, patients with ICD-9-CM code 8. are considered to have code 8.; see Appendix A for details. CKD stage estimates are from a single measurement. For clinical case definition, abnormalities should be present 3 months. costs of chronic kidney disease 9components of costs for ckd All CKD 8.1 8.3 Inpatient/outpatient Inpatient Medical DRG.7 9..1 Surgical DRG 38.1 3. 7.3 Other DRG 39.91 189.38 39.3 Inpatient pass-through.3.13.87 Outpatient OP dialysis.3..7 OP EPO.3. 9.9 IV vitamin D.3.1.7 IV iron..1.9 Other injectables 1.9 7.1 7.88 OP surgery 1.9 1.7 17.78 OP radiology 3.37 19.97 1. OP laboratory 19.13 1.98.3 OP pathology 1.1 1.1 1. Emergency hospital 8.8 7.9 8.79 Clinic..3.9 PT/OT 1.11 1..9 Pharmacy 3.9.98 3. Supplies 1. 13.3 1.71 Other outpatient 19.8 17.3. Skilled nursing facility 18.7 1. 1. Home health agency 113. 98.31 19.9 Hospice.87.1.18 Total 1,1. 1,17.98 1,189.1 Physician/supplier Inpatient surgery Physician 1. 1.38 1. Anesthesia 3. 3.7 3.8 Outpatient surgery Physician 3. 3.73 3.89 Anesthesia.3.7.3 Nephrologist Hospital.9. 7.9 Outpatient.9.3 8.77 Non-nephrologist Hospital 8.37 8.19 8.7 Outpatient.39. 7.7 Dialysis...83 Vascular access 1... Peritoneal access..1. Laboratory 18.13 18.9 1.93 Pathology.9 7. 7.9 Radiology 31. 3.3 3.9 Ambulance 3. 19. 1.8 Durable medical equipment. 3.9.17 Prosthetics..7.89 Diagnostic testing 7.9 8.13 7.71 Cardiovascular 13.9 1. 1.1 Physical medicine.9..8 Opthalmology 7.37 7.71 7.81 Immunosuppressive drugs..8. Prescription drugs 8..3 8.18 Other physician/supplier 3.18 37. 3.1 Total 31..1.

9 9i PPPY costs ($, in thousands) 9 1i PPPY costs ($, in thousands) 9 11i PPPY costs ($, in thousands).. 1. 1..... 1. 1..... 1. 1... Overall PPPY Part D expenditures, by year & at-risk group 7 All Medicare All CKD CKD + DM CKD + DM + CHF No CKD/DM/CHF CKD only CKD + CHF PPPY Part D expenditures, by year & at-risk group: whites 7 All Medicare All CKD CKD + DM CKD + DM + CHF No CKD/DM/CHF CKD only CKD + CHF PPPY Part D expenditures, by year & at-risk group: African Americans 7 All Medicare All CKD CKD + DM CKD + DM + CHF No CKD/DM/CHF CKD only CKD + CHF Between and 7, Medicare Part D net prescription drug costs per person per year (PPPY) rose 1. percent overall, and.9 percent for patients with CKD. Costs for CKD patients, however, reached $1,87, compared to just $1, in the general Medicare population. Costs rise with patient complexity, reaching $,9 for those with CKD and diabetes, and $,9 for those with an additional diagnosis of congestive heart failure (CHF). Costs for patients with no CKD, diabetes, or CHF rose 1. percent, but these patients were the least costly, at $1,19 PPPY. At $,81 PPPY, Part D drug costs in African American CKD patients were.3 percent greater in 7 than costs among their white counterparts. Costs for African Americans with CKD, diabetes, and CHF reached $, PPPY, 9. percent greater than the costs incurred by white patients with the same diagnoses. This is important in the context of the upcoming implementation of the ESRD prospective payment system, which will include certain oral drugs. Not all drugs are covered through the Medicare Part D benefit. Notable exclusions particularly relevant to CKD include all over-the-counter medications (e.g. calcium carbonate) and vitamins and minerals (e.g. cholecalciferol, ergocalciferol). Oral vitamin D hormones (calcitriol, paricalcitol, doxercalciferol) are covered under the Part D benefit, but not all plans cover all available products. see 173 for analytical methods. Point prevalent Medicare patients. Costs are estimated net pay: sum of plan payment & low income subsidy. e

9 i Part D expenditures for Medicare & CKD 9 bi Top Part D prescription drugs used in the CKD population, by frequency & cost 1 usrds annual data report volume one ckd e1 Lines: Expenditures ($, in billions) 3 1 Total Part D Medicare Total Part D CKD 7 3 1 Bars: CKD s % of Medicare Total Part D Medicare expenditures reached $1.3 billion in 7, and CKD patients accounted for $.3 billion. percent of these costs. Cardiovascular and diabetes medications were the Part D prescription drugs used most frequently by CKD patients in 7, while medications for cardiovascular disease, gastrointestinal disease, diabetes, Alzheimer s, psychiatric diagnoses, asthma, pulmonary hypertension, and multiple myeloma topped the list in terms of expenditures. Epoetin alfa is not in the top in terms of frequency, but accounts for the fourth highest expenditures under Medicare Part D, at more than $1 million in 7. see 173 for analytical methods. Includes Part D claims for all CKD patients, defined from claims on a point prevalent basis, for calendar years & 7. Costs are estimated net pay: sum of plan covered payments & low income subsidy payment amounts. Costs & counts in table obtained from percent Medicare sample, & scaled up by a factor of to estimate total Medicare CKD. costs of chronic kidney disease 9overview of medicare part d costs By frequency By cost Generic name # claims Generic name # claims Total cost ($) Furosemide 1,1,7 Insulin 1,3,9 79,8,7 Metoprolol Tartrate 1,87, Clopidogrel 1,98,3, Insulin 1,3,9 Atorvastatin 71,8 7,87, Levothyroxine 81,8 Epoetin Alfa 9,9,9,97 Amlodipine 73, Simvastatin 18,7,739,3 Lisinopril 7,1 Amlodipine 73, 3,,9 Atorvastatin 71,8 Lansoprazole 81, 3,39, Warfarin 7, Carvedilol,3 3,19,3 Hydrocodone-Acetaminophen,7 Esomeprazole, 31,87,9 Clopidogrel Bisulfate 1,98 Quetiapine 17,8 9,11,1 Simvastatin 18,7 Pioglitazone 1,8 8,1,93 Isosorbide Mononitrate,7 Olanzapine 9, 7,31,8 Carvedilol,3 Donepezil 19,,17,3 Atenolol 3,8 Rosiglitazone 1,,8,31 Potassium Chloride 389,9 Pantoprazole,88,9,171 Allopurinol 37,78 Risperidone 9,98 3,77,9 Potassium Chloride 39,78 Darbepoetin Alfa 9,1 3,,39 Digoxin 3,7 Fluticasone-Salmeterol 17,8,7,8 Glipizide 33, Fentanyl 9, 19,,1 Gabapentin 3, Sertraline HCl 3, 17,11,19 Hydrochlorothiazide 33, Metoprolol Tartrate 1,87, 1,7,13 Clonidine 3,1 Escitalopram 3, 1,973,8 Omeprazole 93,8 Tamsulosin,8 1,7,388 Lansoprazole 81, Divalproex 11,1 1,7,83 Metformin 8, Valsartan,7 1,37,81 7 By frequency By cost Generic name # claims Generic name # claims Total cost ($) Furosemide 1,9,78 Insulin 1,393, 3,18,7 Metoprolol Tartrate 1,3,8 Clopidogrel 88, 89,93,87 Insulin 1,393, Atorvastatin 8,78 73,88,3 Levothyroxine 1,178,9 Epoetin Alfa 1, 1,7,3 Lisinopril 1,,8 Esomeprazole 3,9 7,8,7 Amlodipine 1,1,7 Carvedilol 7,,99,987 Warfarin 93,8 Pioglitazone 9,,397, Hydrocodone-Acetaminophen 9, Amlodipine 1,1,7 39,8,8 Atorvastatin 8,78 Donepezil 87,9 38,9,38 Clopidogrel 88, Lansoprazole 77,9 37,8,93 Simvastatin 793,8 Olanzapine 111, 37,1,89 Omeprazole 78,8 Quetiapine 19,8 3,8,3 Carvedilol 7, Pantoprazole 33, 3,7,13 Potassium Chloride 8,8 Fluticasone-Salmeterol 18,7 3,7,7 Atenolol, Risperidone 1,18 7,, Isosorbide Mononitrate 19, Tamsulosin 373,,19,717 Allopurinol 13,7 Oxycodone 19,8 3,8,88 Potassium Chloride,9 Rosiglitazone 189, 3,,73 Glipizide 7,8 Metoprolol Tartrate 1,3,8 3,83,3 Digoxin 3,8 Bosentan,78,, Hydrochlorothiazide 31,1 Valsartan 37, 1,939,79 Gabapentin 1, Omeprazole 78,8 1,97,9 Clonidine 388, Fentanyl 19,,8,9 Metformin 383,3 Aripiprazole,,381,1 Valsartan 37, Lenalidomide 3,98,,

9 13i PPPM net costs for Part D-enrolled CKD pts: cardiovascular medications, 7 Age 9 1i PPPM net costs for Part D-enrolled CKD patients: lipid lowering agents, 7 Age 9 1i PPPM net costs for Part D-enrolled CKD patients: oral vitamin D, 7 Age 1. PPPM expenditures (in dollars) 1 8 1 8 - - -7 7+ Race PPPM expenditures (in dollars) 1 1 1 1 - - -7 7+ Race PPPM expenditures (in dollars).8.... 1..8... - - -7 7+ Race White Af Am Other White Af Am Other. White Af Am Other ACEIs/ARBs/renin inhibitors Beta blockers NDP-CCBs DP-CCBs Statins Fibrates Bile acid sequestrants Cholesterol absorption inhib. All others Doxercalciferol Paricalcitol Calcitriol 9 1i PPPM expenditures (in dollars) Age 3 1 Race 3 1 PPPM net costs for Part D-enrolled CKD pts with diabetes: diabetes agents, 7 - - -7 7+ White Af Am Other Insulin Sulfonylureas Metformin TZDs 9 17i PPPM expenditures (in dollars) Age 3 1 Race 3 1 PPPM net costs for Part D-enrolled CKD patients: diuretics, 7 - - -7 7+ White Af Am Other Any Loop Thiazide Potassium-sparing In 7, PPPM Part D net costs in the CKD population were similar for ACEIs/ ARBs/renin inhibitors and beta blockers. Costs for dihydropyridine (DP) calcium-channel blockers were relatively high, particularly among African Americans. As with ESRD patients (see Volume Two, Chapter Five), statins are the predominant lipid lowering agent used in CKD patients; this is shown in their costs. Low oral vitamin D hormone costs reflect their infrequent use; among African Americans, however, costs are more than twice those incurred by whites and patients of other races. PPPM costs for insulin and thiazolidinediones (TZDs) far outweigh those of sulfonylureas and metformin. And costs of all diuretic therapies are relatively low, reflecting the availability of generics. see 173 for analytical methods. Point prevalent Medicare patients. Populations & costs estimated from the percent Medicare sample; CKD defined from claims. Costs are estimated net pay: sum of plan payment & low income subsidy. e11

1 usrds annual data report volume one ckd e The burdens of ESRD in the U.S. and in Taiwan are among the heaviest in the world. The claims systems of the Taiwanese universal-coverage National Health Insurance (NHI) and the U.S. Medicare system are very similar, allowing us to directly compare people in these two countries who are at the greatest risk and who incur the highest costs those age and older. In 1993, costs for Medicare patients with CKD accounted for 3.8 percent of overall Medicare expenditures. By 8, this had grown to 1. percent, in part reflecting growth in the number of recognized CKD patients. Costs for Taiwanese NHI patients with CKD, in contrast, have consistently accounted for 1 percent of total NHI expenditures since 1. These differences may be due to the nature of the Taiwan NHI data, a closed sample based on the cohort and followed through 8, unlike the open cohort of the Medicare population. The proportion of total costs incurred by NHI patients with CKD and diabetes or cardiovascular disease (CVD) has been relatively stable, in contrast to the steady increase seen for Medicare patients with the same diagnoses. In 8, diabetic CKD patients accounted for.1 percent of total Medicare diabetes costs, slightly higher than the 1. percent of total NHI diabetes expenditures. Costs for CKD patients with CVD contributed 19.8 percent of total Medicare CVD expenditures in 8, compared with 1. percent in Taiwan. see 173 for analytical methods. Point prevalent Medicare & NHI patients age & older. 9 18i Lines: Expenditures ($, in billions) 9 19i Lines: Expenditures ($, in billions) 9 i Lines: Expenditures ($, in billions) Medicare (+) Taiwan (+) 1 1, Total Medicare 1 1 CKD 93 9 97 99 1 3 7 93 9 97 99 1 3 7 8 18 Bars: CKD s percent of program Bars: CKD/DM % of program Lines: Expenditures (NT$, in millions) 9 3 Medicare (+) Taiwan (+) 8 Total Medicare DM CKD+DM 93 9 97 99 1 3 7 8 Bars: CKD/CVD % of program Lines: Expenditures (NT$, in millions) 3 1 Medicare (+) Taiwan (+) Total Medicare CVD 1 1 7 Overall expenditures for CKD in the U.S. & Taiwan Overall expenditures for CKD & diabetes (DM) in the U.S. & Taiwan Overall expenditures for CKD & cardiovascular disease (CVD) in the U.S. & Taiwan CKD+ CVD costs of chronic kidney disease 9ckd costs in the united states & taiwan Lines: Expenditures (NT$, in millions) 3 1 Total NHl CKD 1 3 7 8 Tota NHl DM CKD+DM 1 3 7 8 Total NHI CVD CKD+ CVD 1 3 7 8 9 3 18 1 8 Bars: CKD/CVD % of program Bars: CKD/DM % of program Bars: CKD s percent of program

9 1i PPPM expenditures ($, in 1,s) 9 i PPPM expenditures ($, in 1,s) 9 3i PPPM expenditures ($, in 1,s) Medicare (+) Taiwan (+). 1. 1. 1... 93 9 97 99 1 3 7 3 1 PPPM expenditures (NT$, in 1,s) 9 3 NDM/NCVD CKD+DM CKD+CVD CKD+DM+CVD All 1 3 7 8 Medicare & MarketScan, 7 Taiwan NHI, -8 Medicare (7+) MarketScan (<) PPPM expenditures (NT$, in 1,s) - - - -3 - -1 1 3 - - - -3 - -1 1 3 Months pre- & post-initiation 18 Per person per month (PPPM) expenditures for CKD in the U.S. & Taiwan, by at-risk group Per person per month (PPPM) expenditures during the transition to ESRD in the U.S. & Taiwan, by age & dataset Per person per month (PPPM) inpatient expenditures during the transition to ESRD in the U.S. & Taiwan, by age & dataset 9 3 < Medicare & MarketScan, 7 Taiwan NHI, -8 8 Medicare (7+) MarketScan (<) PPPM expenditures (NT$, in 1,s) - - - -3 - -1 1 3 - - - -3 - -1 1 3 Months pre- & post-initiation < Compared to all Medicare patients, those with CKD and CVD have higher PPPM expenditures; costs are lower, in contrast, for those with CKD and diabetes but no CVD. In the Taiwan NHI database, multiplier effects are consistently shown for CKD patients with CVD, diabetes, or both. Uneven trends in the NHI data are due to the small size of the study sample. see 173 for analytical methods. Point prevalent Medicare & NHI patients age & older. These figures compare PPPM costs for U.S. and Taiwanese ESRD patients in the six months before and after the initiation of dialysis. Total costs rise prior to initiation, particularly in the last month, with hospitalization as the major factor driving this increase. Overall costs for Medicare patients peak in the first month of dialysis, while those for Taiwan NHI patients age and older are highest in month two. The dialysis initiation period thus seems to be longer for Taiwan NHI patients with ESRD. see 173 for analytical methods. Incident Medicare patients age 7 & older, 7, & incident MarketScan patients younger than, 7; incident NHI patients, 8. e13

Between and 7, average Medicare Part D net prescription drug costs per person per year reached $1,87 for CKD patients, compared to $1, for patients in the general Medicare population. Among CKD patients, epoetin alfa is not in the top in terms of most frequently used Part D prescription drugs, but it accounts for the fourth highest expenditures under Part D, at more than $1 million in 7. Overall per person per year costs in 8 reached $19,7 for Medicare CKD patients, and $1,738 for those in the MarketScan database. Compared to those of patients with CKD of Stages 1, costs for those with Stage 3 CKD were 1. percent greater in the Medicare population, and. percent higher among MarketScan patients. Costs for African American Medicare patients with both CKD and congestive heart failure were 1. percent higher in 8 than those for white patients with both diagnoses, at $3,9 compared to $8,89. Total per person per month costs in the month following ESRD initiation reached nearly $1, for Medicare patients in 7, and $31,9 for those in the MarketScan program.1 times greater. Total inpatient/outpatient costs in 8 reached nearly $1,19 for patients with CKD of Stages 3, 1.8 percent higher than the $1,18 incurred by patients in the early stages of the disease. 1 usrds annual data report volume one ckd e1 costs of chronic kidney disease 9 summary