THE ACCESS — AN ATLAS OF THE U.S. DIALYSIS SYSTEMPLATE XI — PROOF STATE — 07|2026

The Money Flow

A GENERATED VIEW · MONEY INTO OUTPATIENT DIALYSIS FACILITIES, AND WHERE IT GOES

Roughly twenty-nine billion dollars a year flows into the country’s outpatient dialysis facilities, and the payer writing the check changes what the same treatment is worth. Solid flows are verified figures; dashed flows are modeled estimates — the distinction is drawn, not footnoted. The margin line at the far right is the headline: sixteen percent all-payer against four and a half percent Medicare, the commercial cross-subsidy in one number. Below, drawn separately because it is four hundredths of one percent of the picture: the fifty-cent withhold that funds the eighteen ESRD Networks.

HOW TO READ · RIBBON WIDTH = DOLLARS · SOLID CYANOTYPE = VERIFIED / COMPUTED · DASHED = MODELED ESTIMATE OR ILLUSTRATIVE SPLIT · ONE ACCOUNTING LEVEL — FACILITY REVENUE, NOT TOTAL MEDICARE-ESRD SPENDING · THE LEDGER CARRIES EVERY FIGURE WITH STATUS AND CITATION
AN ATLAS OF THE U.S. DIALYSIS SYSTEMWIDE GRAMMAR — FLOWPLATE XI
The Money FlowPROOF STATE · ED. 001 · 07|2026
THE PAYERS IN ≈ $29B WHERE IT GOES OUT ≈ $29B · COST SPLIT = MARKET-BASKET WEIGHTS MEDICARE FFS (PROGRAM) CY2026 PPS PROJECTION $6B · VERIFIED FFS BENEFICIARY COST-SHARING 20% COINSURANCE $1.5B · COMPUTED MEDICARE ADVANTAGE MAJORITY OF MEDICARE PATIENTS $10.5B · MODELED EST. COMMERCIAL INSURERS 30-MONTH COORDINATION PERIOD $9B · MODELED EST. MEDICAID PRIMARY + DUAL COST-SHARING $2B · MODELED EST. U.S. OUTPATIENT DIALYSIS FACILITIES ~7,600 CERTIFIED FACILITIES LABOR & STAFFING · $13.3B ~46% OF REVENUE ILLUSTRATIVE DRUGS & SUPPLIES · $5.8B ~20% ILLUSTRATIVE CAPITAL & FACILITIES · $2.3B ~8% ILLUSTRATIVE ADMINISTRATION & OTHER · $2.9B ~10% ILLUSTRATIVE OPERATING MARGIN · $4.6B 16% ALL-PAYER VS 4.5% FFS -- MEDPAC 2024 VERIFIED ONE ACCOUNTING LEVEL — MONEY INTO OUTPATIENT DIALYSIS FACILITIES. NOT THE $55.3B ALL-SERVICES MEDICARE-ESRD FIGURE. THE WITHHOLD — DRAWN SEPARATELY $0.50 PER FFS TREATMENT · ~0.04% OF REVENUE — INVISIBLE AT THE MAIN SCALE U.S. DIALYSIS FACILITIES $12.5M/YR · MODELED EST. CMS — WITHHOLD COLLECTED IPRO -- NETWORKS 1, 6, 9 $1.42M/YR · VERIFIED ALLIANT -- NETWORKS 7, 8, 13, 14 $2.66M/YR · VERIFIED QUALITY INSIGHTS -- NETWORKS 2-5, 10-12 $2.4M/YR · VERIFIED COMAGINE -- NETWORKS 15, 18 $1.64M/YR · VERIFIED QSOURCE -- NETWORKS 16, 17 $1.01M/YR · VERIFIED KHARES NATIONAL COORDINATION HUB (IPRO) $1.54M/YR · VERIFIED RETAINED -- SPECIAL PROJECTS / DATA SYSTEMS $1.83M/YR · COMPUTED COLLECTIONS EXCEED AWARDS — CMS RETAINS A PORTION FOR SPECIAL PROJECTS AND DATA SYSTEMS (CJASN). CONTRACT VALUES ANNUALIZED FROM THE MAY 1, 2026 FIVE-YEAR AWARDS.
MARGIN — RESERVED FOR THE HAND
KEY
A NODE — WHERE MONEY RESTS
VERIFIED / COMPUTED FLOW
MODELED ESTIMATE / ILLUSTRATIVE SPLIT
THE MARGIN NODE — THE HEADLINE
METHODOLOGY · LAST VERIFIED 2026-07-10

Money into U.S. outpatient dialysis facilities, by payer, and where it goes. Medicare fee-for-service program payments ($6.0B) reflect CMS's CY2026 ESRD PPS projection (base rate $281.71/treatment). Medicare Advantage, commercial and Medicaid inflows are The Access estimates modeled from 2022-2024 MedPAC, USRDS and DaVita/Fresenius filings; commercial and MA dollar figures are approximate because payers do not publish facility-level dialysis payments. The cost split uses ESRDB market-basket weights; margins are MedPAC's 2024 freestanding figures — a 16% all-payer margin against a 4.5% Medicare margin, the commercial cross-subsidy in one number. Figures mix years and include modeled estimates; read this as the scale and structure of the money flow, not audited totals.

A note insiders will look for: CMS’s CY2026 fact sheet says $6 billion in 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 as the program-payment figure, and that is the number drawn here. Figures re-anchor after each ESRD PPS final rule (~November).

THE LEDGER — EVERY FLOW, WITH STATUS AND CITATION · LAST VERIFIED 2026-07-10
FROMTOVALUESTATUSNOTE · CITATION
MEDICARE FFS (PROGRAM)U.S. OUTPATIENT DIALYSIS FACILITIES$6BVERIFIEDCY2026 PPS fact sheet: $6B to ~7,600 facilities · CMS-1830-F fact sheet, Nov 20 2025
FFS BENEFICIARY COST-SHARINGU.S. OUTPATIENT DIALYSIS FACILITIES$1.5BCOMPUTED20% coinsurance on ~$7.5B allowed; largely paid by Medigap/Medicaid · derived; CY2026 final rule (+$40M YoY)
MEDICARE ADVANTAGEU.S. OUTPATIENT DIALYSIS FACILITIES$10.5BMODELED EST.MA majority of patients x 1.22 FFS rate · modeled -- MedPAC March 2025 + March 2026 Ch. 12
COMMERCIAL INSURERSU.S. OUTPATIENT DIALYSIS FACILITIES$9BMODELED EST.commercial ~33% of LDO dialysis revenue at ~4-6x Medicare, from ~10-12% of patients · modeled -- DaVita 2024 10-K; JAMA Intern Med 2019
MEDICAIDU.S. OUTPATIENT DIALYSIS FACILITIES$2BMODELED EST.Medicaid-primary + dual cost-sharing residual · modeled -- MedPAC March 2025
U.S. OUTPATIENT DIALYSIS FACILITIESLABOR & STAFFING$13.3BILLUSTRATIVE46% compensation weight · 2020-based ESRDB market basket, CY2026 final rule
U.S. OUTPATIENT DIALYSIS FACILITIESDRUGS & SUPPLIES$5.8BILLUSTRATIVE~20% split of residual · illustrative allocation
U.S. OUTPATIENT DIALYSIS FACILITIESCAPITAL & FACILITIES$2.3BILLUSTRATIVE~8% split of residual · illustrative allocation
U.S. OUTPATIENT DIALYSIS FACILITIESADMINISTRATION & OTHER$2.9BILLUSTRATIVE~10% split of residual · illustrative allocation
U.S. OUTPATIENT DIALYSIS FACILITIESOPERATING MARGIN$4.6BVERIFIED16% all-payer margin, 2024 · MedPAC Dec 5, 2025
U.S. DIALYSIS FACILITIESCMS (WITHHOLD COLLECTED)$12.5M/YRMODELED EST.$0.50 x ~25M FFS Medicare treatments (est.) · 42 CFR 413.178; derivation in Run 3 appendix
CMS (WITHHOLD COLLECTED)IPRO -- NETWORKS 1, 6, 9$1.42M/YRVERIFIEDaward 75FCMC26F0073, $7.08M/5yr
CMS (WITHHOLD COLLECTED)ALLIANT -- NETWORKS 7, 8, 13, 14$2.66M/YRVERIFIED($7.72M + $5.58M)/5yr
CMS (WITHHOLD COLLECTED)QUALITY INSIGHTS -- NETWORKS 2-5, 10-12$2.4M/YRVERIFIED($5.12M + $6.87M)/5yr
CMS (WITHHOLD COLLECTED)COMAGINE -- NETWORKS 15, 18$1.64M/YRVERIFIED$8.20M/5yr
CMS (WITHHOLD COLLECTED)QSOURCE -- NETWORKS 16, 17$1.01M/YRVERIFIED$5.06M/5yr
CMS (WITHHOLD COLLECTED)KHARES NATIONAL COORDINATION HUB (IPRO)$1.54M/YRVERIFIED$7.71M/5yr
CMS (WITHHOLD COLLECTED)RETAINED -- SPECIAL PROJECTS / DATA SYSTEMS$1.83M/YRCOMPUTEDresidual (collected minus awards); CJASN notes CMS keeps a portion · Watnick & Weiner, CJASN 7(11)
THE ACCESS · 07|2026
ED. 001 · GENERATED VIEW SRC: CMS CY2026 ESRD PPS FINAL RULE (CMS-1830-F) · MEDPAC MARCH 2025 / DEC 2025 / MARCH 2026 · USRDS 2025 ADR · MAY 2026 NETWORK AWARDS
PLATE XI · PROOF STATE · LAST VERIFIED 2026-07-10 GENERATED FROM THE ATLAS DATASET
AWAITING THE AUTHOR’S PASS PLATE XII