Kidney Care for the 21st Century

At a time when many Americans are hunkering down in their homes in an effort to protect against the spread of COVID-19, hundreds of thousands of patients suffering from kidney failure have little choice but to continue to venture out and gather in outpatient clinics for dialysis treatment.

Dialysis saves lives. Unfortunately, it may also be putting vulnerable patients at risk when it comes to the ongoing pandemic. This crisis is a stark reminder that it is time to revamp our approach to kidney care in the United States and offer alternative models that protect patients and provide innovative options for treatment.

When dialysis first became a viable treatment option in the 1960s, it was a tremendous leap forward for patients suffering from kidney failure. Because the technology was so new and expensive, the federal government stepped in to ensure near-universal access to this life-changing treatment by extending Medicare coverage to those with renal failure. While this improved the lifespan and quality of life for millions of patients, it also had the unfortunate and unintended consequence of disincentivizing innovation in the treatment of kidney disease — effectively freezing the kidney care model in the 1960s.

Currently in the United States, most patients with end-stage kidney disease receive dialysis treatment at an outpatient facility. This is a time-consuming process, requiring treatment several times per week for hours at a time.

Recently, research published in the Journal of the International Society of Nephrology found that COVID-19 “presents a special threat to patients on dialysis,” particularly for those receiving dialysis treatment in outpatient clinics. As a result of end-stage kidney disease making patients more vulnerable to infections and severe symptoms, having to regularly visit a clinic setting makes it more likely to be exposed and to expose others to the virus.

Fortunately, there are other ways to provide care for these patients. In 2021, patients with end-stage kidney disease will, for the first time, have the option to enroll in private Medicare Advantage plans as a result of bipartisan legislation passed in 2016. 

And in February, the Centers for Medicare and Medicaid Services put forth sensible policies to facilitate this fundamental shift in the nature of kidney care. In its proposed rule, CMS requires providers to compete on price and quality and establishes incentives for Medicare Advantage plans to offer patients greater choice and more convenient access when it comes to managing their chronic disease — making things more conducive to innovation and care model transformation.

There is evidence that this type of approach will work for kidney failure patients on MA plans. In recent years, for other groups of patients with complex medical needs, the health care industry has seen tremendous impact come from innovative and evolving models, such as the movement toward bringing actual care (i.e. intravenous fluids or medications, nebulized therapies, etc.) into the home.

In the Geisinger at Home program, for example, rates of emergency room visits and hospital admissions decreased while quality of life improved by bringing together an integrated team of doctors, advanced practitioners, nurses and other staff, and deploying them directly into the patient’s home. Even absent the threat of a pandemic, such models offer patients the security of knowing they can receive critical health services and treatments in the safety and convenience of their homes.

As proposed, the referenced Medicare rule would create the kind of environment where transformative care models, whether in the home or otherwise, could be extended to end-stage kidney disease patients. By doing so, it would enhance access through innovative, safe and convenient sites, such as the home, while also creating greater flexibility for health plans to develop more competitive networks of dialysis providers, thereby resulting in both improved quality and lower costs overall.

We applaud CMS on its efforts to modernize kidney care, reduce costs and expand access for some of the most vulnerable patients. For the 750,000 Americans living with end-stage kidney disease, change cannot come soon enough. It is time to ensure that they too will soon have real choices when it comes to safe and effective kidney care.


Dr. William Shrank, M.D., is the chief medical officer at Humana and leads Humana’s focus on population health, quality, home health and improving the health outcomes of Humana-covered patients.

Dr. Jaewon Ryu, M.D., J.D., is president and chief executive officer at Geisinger, overseeing all aspects of patient care and working to improve the quality, affordability and experience of care delivered across the enterprise.

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