The decision by Congress in 1972 to fund the ESRD Program was a blessing for hundreds of patients with kidney disease who had little chance of survival. Those lucky few have now mushroomed into more than 500,000 surviving ESRD on dialysis or with a kidney transplant.
That is a positive message for a program that takes up 7% of the Medicare budget each year, but advances in ESRD therapy compared to other medical specialties have been slow. HHS Deputy Secretary Eric D. Hargan summed it up at a keynote presentation during Kidney Week 2018, saying, “Dialysis treatment today is not that much different than it was 60 years ago.” Others in the agency have echoed that comment as the logic for launching the Kidney Innovation Accelerator or KidneyX project. During the next 5 years, the government plans to offer $6.5 million to innovators who can come up with new ways to treat kidney disease. “ ... We are looking for solutions that completely disrupt the way kidney failure is currently treated,” Ed Simcox, HHS chief technology officer, said in a press release about the early stages of the competition. “We are asking innovators, like engineers and scientists, to propose and develop new technologies to redesign treatment for kidney failure.”
However, there are more deep-rooted obstacles with improving treatment for those with kidney failure then developing new devices. One of the most glaring issues is the lack of a Medicare-funded approach to early diagnosis and treatment of CKD. The idea of creating an accountable care demonstration for patients with ESRD and bypassing the most logical starting point – early stage kidney disease – is like giving a musician a guitar without strings. While the Comprehensive ESRD Care Demonstration project, now entering its fourth year, has made some strides in testing the utility of the ESRD Seamless Care Organization model and produced some measurable, albeit somewhat muted results as CMS tinkers with the formula, there is no sense in treating kidney failure without first treating the disease. CMS may be waking up to that idea with discussions about adding a CKD and a transplant component to the demonstration when the first round ends in 2020.
Even more fundamental to improving kidney care is delivering a clear message that nephrologists and the kidney care team, in concert with the desires of the patient, must oversee the treatment regimen. That message was clarified this past year when hundreds of nephrologists, dialysis staff and patients wrote letters to Medicare’s seven administrative contractors (MACs) that were proposing to restrict coverage for more frequent dialysis (MFD), which typically is in-center or at home nocturnal hemodialysis four to six times a week, or short daily hemodialysis. MACs are hired by Medicare to review and pay claims from health care providers and are given the flexibility to modify guidelines on what is covered.
If in fact HHS is serious about pushing its triple aim – improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care – MFD can meet those endpoints. Limiting treatment options is counterproductive, particularly since CMS requires that patients with ESRD receive education on what is available to them.
There is some good news, as we report on page 8 of this issue: Four of the seven MACs are proposing coverage revisions that would ease the restrictions on MFD. The broader guidelines for nephrologists and – more importantly – for patients are an important step. Advocates who lead the letter-writing campaign are awaiting final proposed rules from the MACs to make sure the changes are real – and wait for a signal from the remaining contractors that they will follow suit.
Ultimately, the MFD battle is an example of a government payer like Medicare that talks the talk about wanting to “improve the patient experience” with a value-based care approach, but keeping tight reins on the purse strings. Let them go and be a partner, not a prohibitor, in finding ways to improve kidney care.