Dialysis

Payment mechanism

The payment model for dialysis varies depending on the indication (acute or chronic dialysis) and the settings in which dialysis is provided. 

In many European countries, renal replacement therapy is usually included in the reimbursement for ICU care when a patient with acute kidney injury is admitted. 

Suppose hemodialysis for acute kidney injury is performed in hospital settings (when the patient is hospitalized in the relevant therapeutic unit and receives hemodialysis in a relevant dialysis unit as necessary). In that case, the hemodialysis sessions are either paid on top of the core payment category driven by the indication for admission (e.g., unbundled HRG in England, supplemental payment category in France, or additional reimbursement via ZE category in Germany), or the cost of dialysis is included in the core payment category (Italy, countries of Nordic region). In Germany, hemodialysis is reimbursed as an add-on via the ZE mechanism, which is paid on top of the DRG tariff. The amount of add-on reimbursement depends on the type of procedure, its duration, and the patient’s age. An intermittent or prolonged intermittent (lasting more than six hours) hemodialysis session is reimbursed with a tariff of €169 for patients aged >14 years and €357 for patients <15 years. As for continuous hemodialysis (with a treatment duration exceeding 24 hours), the tariff ranges from €286 to €30,839 depending on the duration of the procedure (from up to 24 hours to more than 2,400 hours).

In most European countries, chronic hemodialysis and peritoneal dialysis are reimbursed via specific payment categories that indicate the number of dialysis sessions in a given period or the settings in which the dialysis sessions are conducted. For example, in England, dialysis for chronic kidney disease with access via hemodialysis catheter for adults in hospital settings is reimbursed per session of hemodialysis via HRG LD01A “Hospital Haemodialysis or Filtration, with Access via Haemodialysis Catheter, 19 years and over” with locally agreed tariffs. The average unit cost per hemodialysis session allocated to the HRG LD01A is £213, based on historical cost data collected by NHS England from all NHS hospitals (National Cost Collection, 2023/24). The Best Practice Tariff (BPT) for this HRG is £148 per hemodialysis session for the 2025/26 financial year. 

In the Netherlands, there are separate DRGs for continuous ambulatory peritoneal dialysis with a coverage period of seven days depending on the settings: when the procedure is performed without hospitalization with overnight stay, it is reimbursed via DRG 140301019 “Continuous Ambulatory Peritoneal Dialysis (peritoneal lavage) per week for renal failure” with an average 2024 cost of €1,510, in hospital admission with an overnight stay, it is reimbursed via DRG 140301020 “Continuous Ambulatory Peritoneal Dialysis (peritoneal lavage) per week in hospitalization for renal failure” with an average 2024 cost of €4,240.

Health technology assessment

Due to established reimbursement policies in European countries, hospital-based dialysis technologies rarely become subjects of HTA. The exceptions include novel portable/home-based dialysis systems and tools for access to dialysis procedures. For example, in 2021, the National Institute for Health and Care Excellence (NICE) published interventional procedure guidance on percutaneous endovascular forearm-arteriovenous fistula creation for hemodialysis access, which concluded that the procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Evidence on the procedure's safety raised no major safety concerns; however, evidence on its efficacy was limited in quantity and quality.