11/5/2019| by Will Maddox
Chronic
kidney disease kills more people than breast or prostate cancer each year, but
you won’t see NFL players wearing socks and gloves to increase awareness, or
massive fun runs raising money to treat it. According to the National Kidney
Foundation, 37 million people in the U.S., or 15 percent of adults, are
impacted by CKD, and around 90 percent of those with the disease don’t even
know they have it.
The
costs of kidney disease are unsustainable. Medicare paid $114 billion for
people with all stages of renal disease in 2016, which was nearly 20 percent of
all Medicare spending that year. It includes $23,558 per person for someone
with non end-stage kidney disease, which is twice the spending for the average
Medicare beneficiary, according to the National Kidney Foundation.
In 2016, Medicare spent $89,000 per dialysis patient and $35,000 for kidney
transplant patient. While just one percent of Medicare beneficiaries have
kidney failure, kidney failure accounts for over seven percent of all Medicare
spending.
But an
executive order signed by President Trump this summer could change the way
kidney disease is treated in the country. With the lofty goal of reducing the
number of people with final stage renal disease by 25 percent by 2030, the policy focuses improving prevention and
education, effective and convenient treatment, and increasing the number of
kidneys available for transplant.
Dallas
Nephrology Associates CEO Dr. Alexander Liang says that one of the reasons CKD
is so under-recognized is because there is no pain or outward signs for most of
the time with the disease. He says it sometimes is not as much of a priority
for primary care physicians, as the lab values are often not urgently alerting.
But with a disease that impacts such a large portion of the country, Liang
welcomes what the executive order could mean for the kidney treatment and
overall healthcare costs.
Kidney
disease is caused by high blood pressure and diabetes, and is treated through
dialysis, which removes toxins from the blood. Another option is a kidney
transplant. Too often, Liang says, physicians and patients aren’t aware of the
problem until the disease is in its late stages, where costly dialysis or
transplants are the only options. By 2030, the order says, there should be a 25
percent decrease in end stage kidney disease patients. Education and awareness
will play a big role in meeting that goal.
The
executive order lays out a policy for the Department of Health and Human
Services to begin a public awareness campaign about the disease, and for the
Centers for Disease Control to improve kidney disease tracking. Medicare
payment models are also incentivizing education and prevention are part of the
plan.
At
Dallas Nephrology Associates, one of the three largest nephrology practices in
the country, a series of classes and programs help patients learn about the
disease, treatment options, and how lifestyle choices can improve or hurt the
kidney. “We are making sure people understand the changes they need to make to
prevent the progression,” Liang says.
Another
piece of the executive order emphasizes less costly and more convenient
treatment, which often means home dialysis. Home dialysis is much cheaper for
the medical system, which is usually paid by Medicare for patients with kidney
disease. With equipment that can be used at home, fewer staff and facilities
are needed. According to Modern Healthcare, in-center dialysis treatment
costs $256 per patient, while only costing
$215 to deliver the same care at home in 2017. Liang says it is about building
confidence of the patients, who are often overwhelmed and nervous about the
equipment.
It is
also much more convenient. Dialysis can take several hours, and reporting to a
hospital or dialysis center three times a week for four hours can prevent a
patient from working, traveling, or living their lives. Peritoneal dialysis can
even be done at night at home while the patient is asleep.
Liang
says the rate of at home dialysis is about 12 percent right now, but that
executive order is a good first step to move more patients to their home. It
says that by 2025, 80 percent of patients starting dialysis should start at
home or get a kidney transplant. There is some debate about whether the
dialysis mammoths DaVita and Fresenius are on board with the move toward at
home dialysis, as an empty chair in a center means less income for them. The
companies say they are all in on at home dialysis, but
CVS Health is also entering the market for home dialysis, which
could be a major disruptor and could increase the move to at-home care.
By
2025, the policy says the number of kidney transplants in the US should double
because transplant is a less expensive than years of dialysis. Increasing
donors is also about education, letting people know about the low risks for
donors and recipients alike. One key point, Liang says, is that recipients
of kidney transplants can lose their Medicare coverage after receiving
transplant. An extension of coverage could increase transplants. Also, added
benefits for donors such as making sure they don’t lose time at work or that
the surgery doesn’t count against them on their insurance are other measures
that may increase kidney transplants.
Sharing
the risk is also a way to innovate and save costs treating kidney disease. At
DNA, which sees 10 percent of patients on dialysis in the entire state, Liang
says they have created an ACO for dialysis patients, where they share some of
the risk for the patients’ cost. Partnering with dialysis provider Fresenius,
the practice was able to educate patients, divert emergency room visits and
ended up saving $5 million in 2016 alone. Reducing hospital readmission with
care navigation and transportation vouchers were also part of the cost reducing
measures.
“If you
look at medicine in general, we need to be able to coordinate care, between
primary care and specialists, specialists and specialists, dialysis units and
doctors, and doctors and hospitals so they can integrate and share
information,” Liang says. “The system is going to collapse. There are not
enough dollars to support the growth of dialysis.”
Liang
says the practice knew that CMS would soon mandate these cost sharing measures,
so they have been getting ahead of the requirements. While the details about
the policy have yet to be determined by HHS, getting in this mindset will
hopefully pay dividends in the future. “We knew that this would eventually
coming down the pipe,” he says. “We have made a lot changes in our practice, so
we have the infrastructure to do it now.”
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