← the access Reviewed as of 15 July 2026
THE ACCESS · HOW DOES THE MONEY MOVE?

The Money Flow

Roughly twenty-nine billion dollars a year into U.S. outpatient dialysis facilities—facility revenue, not total Medicare ESRD spending—and where it goes. A sixteen percent all-payer operating margin against four and a half percent on Medicare fee-for-service (freestanding facilities, 2024): the commercial cross-subsidy in one number.

TEXT ALTERNATIVE ↓
WIDE DRAWING · SCROLL SIDEWAYS TO READ IT ALL · THE FULL CONTENT IS ALSO IN WORDS BELOW
A node—where the money rests
A verified or computed flow—ribbon width is the dollars
A modeled estimate or illustrative split—drawn dashed, never solid
The operating margin—the flow this plate is about
Reviewed as of 15 July 2026 Changelog

The drawing in words

  1. ONE ACCOUNTING LEVEL—money into U.S. outpatient dialysis facilities (~7,600 certified facilities), all payers in, costs and margin out. This is NOT the $55.3B all-services Medicare-ESRD figure. Payer mix is 2023-24 actuals; the Medicare fee-for-service inflow is a CY2026 projection. Solid flows are verified or computed; dashed flows are modeled estimates or illustrative splits. [1 · 2]
  2. IN—Medicare FFS (program), CY2026 PPS projection: $6B. VERIFIED (CMS-1830-F fact sheet, Nov 20 2025). [1]
  3. IN—FFS beneficiary cost-sharing (20% coinsurance): $1.5B. COMPUTED. Largely paid by Medigap or Medicaid. [3]
  4. IN—Medicare Advantage: $10.5B. MODELED ESTIMATE (MedPAC March 2025 + March 2026 Ch. 12). [4]
  5. IN—Commercial insurers (the 30-month coordination period): $9B. MODELED ESTIMATE. About 33% of large-dialysis-organization revenue at 4-6x Medicare, from about 10-12% of patients (DaVita 2024 10-K; JAMA Internal Medicine 2019). [5 · 6]
  6. IN—Medicaid (primary plus dual cost-sharing): $2B. MODELED ESTIMATE (MedPAC March 2025). [4]
  7. TOTAL IN—approximately $29B a year. COMPUTED: the sum of the five inflows above. About three quarters of it ($21.5B—Medicare Advantage, commercial, Medicaid) is modeled estimate, not reported revenue. [1 · 3 · 4 · 5 · 6]
  8. OUT—labor and staffing (~46% of revenue): $13.3B. ILLUSTRATIVE (2020-based ESRDB market basket, CY2026 final rule). [3]
  9. OUT—drugs and supplies (~20%): $5.8B. ILLUSTRATIVE.
  10. OUT—capital and facilities (~8%): $2.3B. ILLUSTRATIVE.
  11. OUT—administration and other (~10%): $2.9B. ILLUSTRATIVE.
  12. OUT—OPERATING MARGIN, the followed flow: $4.6B. COMPUTED—a verified 16% all-payer margin rate (MedPAC, Dec 2025; freestanding facilities, 2024) applied to the modeled $29B revenue base. The RATE is verified; the DOLLAR figure is not. [4]
  13. TOTAL OUT—approximately $29B a year. COMPUTED: the four cost lines are illustrative allocations of revenue on market-basket weights; the operating margin is the headline. [3 · 4]
  14. THE WITHHOLD, DRAWN SEPARATELY—$0.50 per fee-for-service treatment, about four hundredths of one percent of revenue, invisible at the scale of the main flow. [7]
  15. WITHHOLD—facilities to CMS: $12.5M/yr. MODELED ($0.50 x ~25M FFS treatments; Social Security Act 1881(b)(7)). [7]
  16. WITHHOLD—CMS to IPRO (Networks 1, 6, 9): $1.42M/yr. VERIFIED. [8]
  17. WITHHOLD—CMS to Alliant (Networks 7, 8, 13, 14): $2.66M/yr. VERIFIED. [8]
  18. WITHHOLD—CMS to Quality Insights (Networks 2-5, 10-12): $2.4M/yr. VERIFIED. [8]
  19. WITHHOLD—CMS to Comagine (Networks 15, 18): $1.64M/yr. VERIFIED. [8]
  20. WITHHOLD—CMS to Qsource (Networks 16, 17): $1.01M/yr. VERIFIED. [8]
  21. WITHHOLD—CMS to the KHARES national coordination hub (IPRO): $1.54M/yr. VERIFIED. [8]
  22. WITHHOLD—the residual, collected minus the six Network awards: $1.83M/yr. COMPUTED. [8]
  23. A NOTE INSIDERS WILL LOOK FOR—CMS’s CY2026 fact sheet says $6 billion in PPS program payments; one secondary source (Applied Policy, Nov 2025) reports $8.2 billion. The fact-sheet series—$6.6B (CY2025), $6.0B (CY2026), $6.2B (CY2027 proposed)—supports $6B, and that is the number drawn here. Figures re-anchor after each ESRD PPS final rule (about November). [1 · 9]
  24. HOW TO READ THE FIGURES—Medicare Advantage and commercial dollar figures are approximate because payers do not publish facility-level dialysis payments. Figures mix years and include modeled estimates: read this as the scale and structure of the money flow, not audited totals.

BRACKETED NUMBERS TRACE EACH LINE TO THE SOURCE LIST BELOW · EVERY SOURCE IS HELD IN THE REFERENCES LEDGER WITH ITS LOCATOR, ITS LAST-CHECKED DATE, AND HOW IT WAS VERIFIED