Evaluating new efforts to revamp kidney care

Chronic kidney disease affects more than 30 million adults in the United States. Each year, 100,000 patients transition to the most advanced stage of kidney disease – end-stage kidney disease – where they require either dialysis or a kidney transplant in order to survive.

The costs of advanced kidney disease care are high and mortality in dialysis is comparable to many cancers. Because of a federal law passed in 1972, patients become automatically eligible for Medicare coverage after they develop end-stage kidney disease, regardless of their age.

This means that the federal government bears much of the cost of caring for this population.  The less than 1% of Medicare beneficiaries with end-stage kidney disease account for more than 7% of all Medicare expenditures.

Despite high costs and poor health outcomes, little has changed in how end-stage kidney disease care is delivered over the past four decades, and there are few interventions available to slow the progression of chronic kidney disease.

While many patients would survive longer and have a better quality of life if they received a kidney transplant, a shortage of organs available along with other barriers prevent many patients from getting a transplant.

And, despite a widespread belief among healthcare providers that many patients would have improved quality of life if they received dialysis at home rather than at a dialysis facility, the use of home dialysis in the United States is low.

Recognizing a need to improve kidney care delivery, President Trump and the Secretary of Health and Human Services, Alex Azar, announced on July 10 a department-wide initiative within HHS to transform kidney disease care.

The initiative will focus on three main areas. First, it aims to reduce the number of Americans with end-stage kidney disease. Second, it sets the ambitious goal of having 80% of Americans with end-stage kidney disease either receiving dialysis at home or with a functioning kidney transplant by 2025.

Third, it aims to double the number of kidneys available for transplant by 2030. The administration plans to accomplish these goals with policies that boost innovation, transform care delivery, educate the public about kidney disease, and increase the availability of organs for transplant.

This announcement is exciting for both patients with kidney disease and healthcare providers.  Any success in making kidney transplants more available and in finding ways to prevent the progression of kidney disease holds the promise of improving patient health while at the same time reducing healthcare costs.

And, efforts to increase patients’ access to different treatment options – such as home dialysis – and to create reimbursement incentives that reward the delivery of patient-centered care, could lead to meaningful improvements in the lives of patients with kidney disease.

However, this initiative is not without dangers. Importantly, many details have yet to be announced. Also, home dialysis is not for everybody. Ideally, physicians and dialysis providers should be educating patients on their options for receiving dialysis at home and in-center, and working with their patients to determine the best treatment option for them.  Strong economic incentives that simply favor home dialysis, irrespective of patient preferences and realities, could leave some patients worse off.

While innovations that prevent progression to end-stage kidney disease and efforts to successfully increase the availability of kidneys for transplantation can reduce costs, innovation in medicine more commonly leads to higher costs. It will be critical that the new initiatives focus on cost-effective innovations.

The recent executive order represents an exciting step toward advancing kidney disease care beyond the status quo. I sincerely hope that this will lead to new breakthroughs in disease prevention and cost-effective treatment options.

But, as sweeping as this initiative appears to be, it’s only a first step. It will be important that the consequences of new incentives on the cost and quality of care are closely monitored, and that policymakers remain committed to improving upon these efforts.

-By Dr. Kevin Furman Erickson, assistant professor of medicine, section of nephrology at Baylor College of Medicine and health policy scholar in the Center for Medical Ethics and Health Policy


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