By
Eugene Lin
August 1, 2019 at 5:00 am ET
As a kidney doctor and health policy researcher, I am surprised that President Donald Trump’s initiative to remake kidney treatment has not gotten more attention.
The July 10 announcement itself made news and was widely praised, but within 24 hours it was relegated to the nether regions of the national conversation. Perhaps that is because it involved technical changes to Medicare compensation rates, which don’t exactly excite the Twittersphere.
If so, that’s too bad. Of all the health policy changes that have been enacted since Obamacare, this one ranks near the top in terms of positively affecting both the national budget and the lives of millions of patients.
We need to keep paying attention because so much is at stake. Laudable goals could become dangerous mandates, and incentives that enhance care in one area could also reduce access to other essential services.
First, some background. Kidney disease is one of the more pernicious maladies affecting Americans. When kidneys become damaged and cannot clean the blood, wastes and extra water build up in the body, eventually causing health problems, including heart disease, leading to hospitalizations and even death.
The Centers for Disease Control and Prevention estimates that 15 percent of adults will develop chronic kidney disease, with many unaware until it is too late. When it progresses to end-stage renal disease, transplants or dialysis are the only ways to avoid death.
Since 1973, Medicare has covered dialysis for all Americans with ESRD no matter how old they are — the only disease with that status. Medicare spent $35 billion on ESRD patients in 2016 and an additional $79 billion on patients age 65 and older suffering from chronic kidney disease.
Each year, more than 450,000 Americans enter dialysis clinics to have machines clean their blood in multiple three-hour sessions each week. The use of clinic dialysis as the default treatment is one of the targets of the new initiative, and rightly so. Not only is it costly — an average of $89,000 a year — it can also be disruptive and debilitating to patients’ lives.
I recently saw a patient, a balding, muscular, bearded man in his mid-50s with a quiet and polite demeanor, in the hospital. His symptoms — itching, poor appetite, weight loss and fatigue — were ominous signs of kidney failure.
He had been refusing clinic dialysis because it would take him away from his contracting business, and his family desperately needed the income. His outpatient physicians had not discussed other options with him, including home dialysis, which can be done overnight. He agreed to try home dialysis and a few months later reported substantial improvement in symptoms while continuing to work.
Medicare pays nephrologists (aka kidney doctors) offering clinic dialysis 20 percent more than nephrologists offering home dialysis, giving doctors an incentive to send patients to dialysis clinics. The Kidney Health Initiative would change that terrain, installing incentives to promote home dialysis, which with proper training can be done daily overnight when a patient sleeps while obtaining similar outcomes to clinic dialysis. Currently, only 12 percent of dialysis patients get home treatment.
The initiative would also provide incentives to help patients get off the transplant waiting list, which now numbers over 100,000. Among other steps, it would compensate donors for lost wages and childcare and would seek to improve the development of artificial kidneys. Importantly, it would also pay doctors more to provide high-quality care for chronic disease with the aim of stalling the progression to ESRD.
The goals are to reduce the number of Americans developing ESRD by 25 percent by 2030; have 80 percent of new patients with ESRD in 2025 either receiving dialysis at home or receiving a transplant; and double the number of kidneys available for transplant by 2030.
The initiative needs to be watched carefully because Medicare intends to accomplish its goals through a complicated set of mandatory and voluntary payment models for doctors and clinics. The goal of getting 80 percent of new patients with ESRD out of dialysis clinics, for example, might be too ambitious.
It is vital that incentives be structured to ensure that patients who need in-center dialysis don’t lose access to that service. Patient outcomes and preferences should be monitored closely so that the initiative does not leave anyone behind or create new problems.
The administration is proceeding without congressional approval because it has authority from the Center for Medicare and Medicaid Innovation, which was created by the 2010 Affordable Care Act. Ironically, the Justice Department has argued in a federal appeals court that the entire act should be declared unconstitutional.
If that view prevails, CMMI could lose its mandate, and we may not need to worry about monitoring any of the models. At that point, the kidney initiative might once again return briefly to the news, with stories proclaiming its demise rather than its accomplishments.
Eugene Lin, MD, is an assistant professor of nephrology at the Keck School of Medicine and a clinical fellow at the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.
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