Thursday Shorts: Dialysis cost, HPV vaccine, and PE-owned gastroenterologists

July 3, 2025

A. Dialysis costs are higher in geographies with less competition

Dialysis Facility Count by Chain Ownership

Source: Xia, et al JAMA Health Forum, June 18, 2025

The United States has the most expensive dialysis in the world, and our dialysis outcomes are worse than in most other developed countries. Dialysis in centers is generally administered three times a week, and most will require this for the rest of their lives unless they are able to get a kidney transplant. About a half million in the US are currently on dialysis. The dialysis market is quite concentrated, and two companies (Fresenius and DaVita) represented 59% of the market in 2005 and now represent 77% of this market. About one-third of US residents live in highly concentrated service areas dominated by one or both companies, limiting choice and competition.

Research published in JAMA Health Forum compared the cost of dialysis sessions and the compensation received by nephrologists. They found that in markets that were most concentrated, costs per dialysis center and compensation of nephrologists was highest. In markets with only a single large chain, each dialysis session cost $495 more, and the nephrologist was paid $565 more.

Employer sponsored health insurance is responsible for paying for dialysis for about the first three years, after which those with end-stage kidney disease are eligible for Medicare coverage. This excess cost for dialysis in concentrated markets increases the cost of employer sponsored health insurance. Extra payment to nephrologists can encourage them to prescribe dialysis in centers, as opposed to home dialysis, which might be preferable for many with failing kidneys.

B. HPV vaccine associated with regression of actinic keratosis

JAMA Dermatology reported last month that HPV vaccination administered to those with actinic keratoses (AKs- severe skin sun damage - usually scaly white lesions that are premalignant) had statistically significant reductions in AKs compared to those randomized to receive a placebo shot. The researchers cite previous research demonstrating that HPV vaccine is associated with decrease in basal cell and squamous cell skin cancer as well. This was a small study, and the average age was in the mid-70s.

Human papillomavirus is clearly ‘oncogenic.’ Infections raise the risk of cervical and throat cancer, and HPV viral particles have sometimes been found in thyroid cancers. The evidence that the HPV vaccine prevents cervical cancer is very strong. It could take decades of observation to show the impact of vaccination on throat (head and neck) cancers.

C. Private equity increases colonoscopy prices, and has no impact on quality

Researchers found that gastroenterology practices that were acquired by private equity (PE) companies had a 4.5% increase in allowable unit price, and a 6.7% increase in allowable price in markets with a high concentration of PE-owned practices. The PE practices had 16% higher revenue per physician, 12% more colonoscopies per physician, and 11.3% more patients having colonoscopies. This could improve access and help screen more plan members, but will also increase costs. The researchers found no quality differences between the practices owned by private equity and those owned by hospitals or by gastroenterologists.

An accompanying editorial noted that one in 8 gastroenterologists were employed at practices now owned by private equity companies.

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Hope your July 4 is happy; I’ll take tomorrow off and have Longforms (and an animal photo) on Saturday.

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