Presentation (CTI)

OBJECTIVES: Despite a 54-fold inpatient cost gradient from CKD Stage 2 to ESRD, 25.1 million U.S. adults 55+ remain undiagnosed at actionable stages. This study applies behavioral economic theory to explain why late-stage CKD persists as a stable equilibrium, quantifies its fiscal consequence using public federal data, and tests whether a coverage default change disrupts it at the population level.
METHODS: The treat-late equilibrium is modeled as a three-mechanism behavioral trap: (1) hyperbolic discounting suppresses asymptomatic CKD detection (Laibson, 1997); (2) treatment-weighted reimbursement steers providers toward late-stage procedural care; (3) a structural split-incentive — Medicaid bears screening costs while Medicare captures ESRD savings — locks the equilibrium institutionally. Fiscal burden applies Golestaneh et al. (Am J Manag Care. 2017;23[10 Suppl]:S163-S172) stage-specific cost benchmarks to undiagnosed counts from NHANES 2017-2020 × ACS 2023 (99.1M adults 55+) versus USRDS 2024 diagnosed counts. Equilibrium disruption is tested via difference-in-differences on a 2003-2023 USRDS state-year panel (N = 1,071; 51 states × 21 years) using Medicaid expansion as the coverage default treatment, with state and year fixed effects.
RESULTS: The equilibrium generates $228 billion in annual undiagnosed CKD burden: $88.8 billion at Stage 2 (14.9M undiagnosed; 20% diagnosis rate) and $92.3 billion at Stage 3a (8.0M undiagnosed). Screening at 60% uptake yields $38.9 billion in annual net savings (21:1 ROI; $40/person). Medicaid expansion states show progressively lower ESRD incidence post-2014; cumulative alignment savings reach $562 billion (2003-2023) — consistent with Thaler and Sunstein's nudge framework: coverage defaults shift CKD trajectory without individual initiative.
CONCLUSIONS: Late-stage CKD is a behavioral equilibrium, not an information failure. The $228 billion burden is its fiscal price. Coverage defaults are the highest-leverage policy instrument, shifting screening behavior system-wide at the margin. This framework applies to European HTA contexts where payer fragmentation creates analogous split-incentive barriers to preventive nephrology investment.