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Kidney Week

Abstract: SA-OR058

Consolidation in the Dialysis Industry in the Era of Health Reform, 2006-2013

Session Information

  • Hemodialysis Potpourri
    November 09, 2019 | Location: 144, Walter E. Washington Convention Center
    Abstract Time: 04:30 PM - 04:42 PM

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Sloan, Caroline E., Duke University, Durham, North Carolina, United States
  • Hoffman, Abby, Duke University, Durham, North Carolina, United States
  • Maciejewski, Matthew L., Duke University, Durham, North Carolina, United States
  • Coffman, Cynthia, Duke University Medical Center, Durham, North Carolina, United States
  • Sanders, Linda L., Duke University Medical Center, Durham, North Carolina, United States
  • Hirth, Richard A., University of Michigan, Ann Arbor, Michigan, United States
  • Lee, Shoou-Yih Daniel, University of Michigan, Ann Arbor, Michigan, United States
  • Wang, Virginia, Duke University, Durham, North Carolina, United States

In the last 15 years, the dialysis industry has become dominated by two for-profit large dialysis organizations (LDO) that control 85% of the market. For-profit LDOs have been shown to have higher costs, greater use of expensive medications, lower transplant rates and higher mortality rates. We describe trends in dialysis industry consolidation in the current era of health reform, 2006-2013, and identify factors that put small dialysis chains and independently-owned facilities at risk of closure or acquisition by LDOs.


We conducted a retrospective cohort study of non-federal US outpatient dialysis facilities that were independently-owned or affiliated with small chains (<20 facilities) for >1 year in 2006-2013. These facilities were deemed to be eligible for acquisition by large dialysis organizations. We used data from Center for Medicare and Medicaid Services, US Renal Data System and Area Health Resource File to evaluate facility and market characteristics throughout the study period. The outcome of interest was change in dialysis facility ownership (i.e. acquisition) or facility closure. We used a generalized estimating equation with a logit link, clustered at the regional level, to examine the association between facility characteristics and closure or acquisition.


Overall, 1686 dialysis facilities (27% of all US facilities) were eligible for acquisition for at least one year of the study period; 61% were independently-owned and 39% were affiliated with small chains. The number of independently-owned and small chain-affiliated facilities declined by 192 from 2006 to 2013 (1356 to 1164), while LDO-affiliated facilities increased by 1473 (3214 to 4687). Facilities at highest risk of acquisition or closure were not-for-profit (p<0.001), smaller in size (p=0.02), and in regions with lower hospital density (p=0.001) and more monopolistic markets (p=0.006).


Small dialysis chains and independent facilities retain a declining share of the dialysis market. Policy makers should work to maintain (or even increase) the current diversity of dialysis organizations and help maintain competition in markets at risk of antitrust violation. Efforts should be directed toward facilities that are particularly vulnerable to acquisition and closure.


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