THREE ESSAYS ON END-STAGE RENAL DISEASE TREATMENT, POLICIES, AND MARKETS

The end-stage renal disease (ESRD) population presents a significant challenge in the healthcare system due to its high cost and complex care needs. Despite comprising only 1% of the Medicare fee-for-service population, the 800,000 Americans with ESRD accounted for a disproportionate amount of healthcare spending, estimated at 7% ($37.3 billion) of Medicare fee-for-service expenditures in 2020. These individuals receive care in a highly consolidated market dominated by large for-profit dialysis organizations, associated with higher mortality rates, increased hospitalization rates, lower quality of care, and lower transplant rates than nonprofit facilities. The financial burden is projected to intensify with an aging population and the potential increase in ESRD cases. Understanding and addressing the complexities of ESRD treatment, policies, and market dynamics are crucial for improving health outcomes and ensuring the long-term sustainability of healthcare delivery. This dissertation investigates three critical issues related to inefficiencies in US ESRD care. The first chapter examines the effectiveness of policy interventions, such as mandatory Prescription Drug Monitoring Programs, in addressing potential misuse among dialysis patients who are more susceptible to adverse outcomes due to impaired kidney function. The second chapter focuses on dialysis facility acquisition and waiting time for kidney transplants. It explores whether access to transplant, a preferable treatment option for most ESRD patients, would be affected after independent facilities are acquired by large chains. The third chapter explores the relationship between the consolidated dialysis market and the Affordable Care Act Health Insurance Marketplace. Previous studies indicate that large dialysis organizations have leveraged their bargaining advantage from consolidation to secure higher reimbursement rates in other private insurance markets. This chapter investigates whether similar practices are employed in the Marketplace, leading to increased premiums and federal expenses for premium subsidies. By using comprehensive administrative and claim data, this dissertation aims to contribute valuable insights into enhancing ESRD care and alleviating the financial burden faced by the healthcare system