A Model-Based Public-Payer Investment Appraisal of a National Home Hemodialysis Program in Greece: A Net Present Value Analysis

Background: In-center hemodialysis is the dominant kidney replacement therapy modality in Greece and generates substantial recurring expenditure for the public payer. Home hemodialysis is not currently implemented at national scale, but it may reduce long-term public expenditure if early investment in training capacity, equipment and home support is recovered over time. Objective: To evaluate, from the Greek public-payer perspective, the discounted budget impact and net present value (NPV) of implementing a national home hemodialysis program for 300 patients. Methods: We developed a deterministic investment-appraisal model comparing gradual implementation of home hemodialysis with continued in-center hemodialysis for the same projected cohort over 10 years. The in-center comparator was informed by a 2022 Greek patient-level micro-costing study. Home hemodialysis expenditure was constructed from explicit patient-flow equations, resource quantities, unit costs, capital purchases and hospital-tariff offsets. Annual incremental savings were discounted at 3% in the base case. Alternative discount rates, deterministic one-way sensitivity analyses and program-scale scenarios were examined. Fiscal benefit–cost ratio (BCR) and return on investment (ROI) were also calculated. Results: Undiscounted 10-year public expenditure was EUR 69,681,804 for home hemodialysis and EUR 86,700,267 for continued in-center hemodialysis, yielding savings of EUR 17,018,463. During the first 5 years, the program required EUR 1,724,012 in additional expenditure. At a 3% discount rate, NPV was EUR 12,696,564, the fiscal BCR was 2.89, fiscal ROI was 189.3% and discounted payback occurred during year 6. NPV remained positive at 5% (EUR 10,391,382) and across all tested one-way scenarios (range EUR 706,179 to EUR 24,686,948). Conclusions: The modeled national home hemodialysis program generated a positive 10-year public-payer NPV under the base-case and tested sensitivity assumptions. A positive NPV is not, however, a formal Greek health-system decision rule and does not capture health outcomes, patient and family costs, or equity. The findings support staged pilot implementation and prospective collection of Greek real-world data before wider rollout.