Presentation (CTI)

OBJECTIVES: To integrate evidence across three national analyses—Medicaid policy misalignment, infrastructure inequities, and cost‑effectiveness modeling—to identify high‑value, equity‑enhancing strategies for CKD detection and management among adults aged 55+.
METHODS: National datasets (NHANES, USRDS, CMS Part D, SAHIE, ACS) were triangulated to characterize dissemination patterns, prescribing mix, and infrastructure gaps across major U.S. cities and more than 2,500 counties stratified by Medicaid expansion status. A cohort of 1,000 adults aged 55+ was modeled using a decision tree (Year 1) and life table (Years 2-10) from the Medicaid/public payer perspective. Inputs included CKD prevalence (20%), test sensitivity (90%) and specificity (85%), screening cost ($40), confirmatory cost ($120), annual treatment cost ($800), avoided costs ($1,200), ESRD cost ($90,000), and QALY gain (0.02 per treated patient‑year). Outcomes included incremental cost, QALYs, ICER, and net monetary benefit (NMB). Sensitivity analyses varied screening cost, treatment cost, ESRD cost, QALY gain, and linkage rates.
RESULTS: Dissemination failures were concentrated in low‑literacy ZIP codes, where ESRD‑dominant prescribing indicated late‑stage, reactive care. Medicaid expansion counties demonstrated higher linkage to care and greater QALY gains. CKD screening for adults 55+ was cost‑saving, with a 10‑year discounted incremental cost of −$556,600 and 31.6 QALYs gained (ICER −$17,600/QALY; NMB +$2.14M). National implementation (65M adults 55+, 60% uptake) projected 897,000 QALYs gained and $16B in net savings.
CONCLUSIONS: Conclusions: Structural inequities in Medicaid financing and diagnostic infrastructure contribute to preventable ESRD burden. CKD screening for adults 55+ is a dominant strategy—cost‑saving, equity‑enhancing, and robust across assumptions. Aligning Medicaid policy with evidence‑based screening can generate substantial health and financial gains.