Differences in Hemodialysis Claim Patterns Across Membership Types Among Patients With Renal Failure Based on National Health Insurance Data From 2017 to 2022: Cross-Sectional Analysis

BACKGROUND: Chronic kidney disease and end-stage renal disease are major contributors to the disease burden in low- and middle-income countries, including Indonesia. Despite the expansion of universal health coverage through Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan, Indonesia's national health insurance program, disparities in access to hemodialysis persist across different socioeconomic and geographic groups. Understanding these inequities is critical to advancing equitable health care access. OBJECTIVE: This study aimed to examine disparities in hemodialysis claim patterns as a proxy for access among adult patients with renal failure enrolled in BPJS, focusing on differences by membership type, sex, age, geographic region, urbanicity, and facility ownership. METHODS: We conducted a cross-sectional analysis of 38,383 anonymized health insurance claims between 2017 and 2022 for patients with renal failure who were aged ≥18 years. The primary outcome was receipt of hemodialysis. We used multivariate logistic regression to estimate adjusted odds ratios (aORs) for receiving hemodialysis across BPJS membership types and other covariates. Subgroup analyses were performed by sex, facility ownership, urbanicity, and geographic region. Robust SEs and probability weights were applied to account for the sample design. RESULTS: Of the total renal failure claims, 75.6% (29,017/38,383) involved hemodialysis. Compared with individuals in the lowest income group (ie, members subsidized under the national government budget), informal workers (aOR 1.56, 95% CI: 1.34-1.82); P<.001) and members subsidized under the local government budget (aOR 1.31, 95% CI: 1.05-1.63); P=.017) had higher odds of receiving hemodialysis, while formal sector workers had lower odds (aOR 0.81, 95% CI: 0.68-0.98); P=.028). Disparities were more pronounced in rural areas and among women; for example, in rural regions, locally subsidized members had more than twice the odds of receiving hemodialysis compared with nationally subsidized members (aOR 2.40, 95% CI: 1.78-3.23). Men had higher odds than women (aOR 1.17, 95% CI: 1.04-1.32), and younger patients were more likely to receive treatment than older ones. Regional disparities were stark, with patients in Java or Bali having much greater access (aOR 8.30, 95% CI 5.33-12.94) compared with those in eastern Indonesia (Papua, Maluku, and Nusa Tenggara). Patients treated at private facilities (aOR 1.30, 95% CI 1.13-1.50) and in outpatient settings (aOR 3.74, 95% CI 3.36-4.17) were more likely to receive hemodialysis, whereas those in lower-level hospitals or clinics were less likely to access care. CONCLUSIONS: Substantial disparities in hemodialysis claim patterns (as a proxy for access) exist within Indonesia's national health insurance system, particularly affecting low-income populations, rural residents, women, and those in less advantaged regions. Policy efforts to enhance health infrastructure, improve service distribution, and reduce geographic and socioeconomic barriers are urgently needed to support equitable access to renal care services and achieve universal health coverage goals.

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