First Word

CMS, HHS need to identify next steps for Advancing American Kidney Health

ASN Kidney Week had the potential for a kidney care trifecta: 13,000 professionals and members of industry gathered in the nation’s capital; Medicare policymakers who regulate the $114 billion-a-year ESRD program were available for discussion; and the 4-month-old Advancing American Kidney Health, a new initiative that will likely re-shape kidney care for the next quarter century, was on the table for review.

The winning outcome during ASN Kidney Week would have been an opportunity to firm up details and get a better understanding of what the new policy would look like as the renal community makes attempts to reach the following ambitious goals of the initiative:

  • reduce the number of Americans developing ESRD by 25% by 2030;
  • have 80% 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.

ASN President Mark Rosenberg, MD, bestowed HHS Secretary Alex M. Azar II with the ASN’s President’s Medal during opening ceremonies. In his comments, Azar said, “there is no time to waste” in moving forward with developing policy to reduce kidney disease and make more kidneys available for those who need a transplant.

Much left to do

Mark E. Neumann

With a Jan. 1 deadline looming for finalizing the details of the mandatory ESRD Treatment Choices (ETC) model, Azar’s comments are on target. However, he and his team offered few answers as to its implementation date at the meeting and reaction to comments on the details of the plan.

The proposed rule has drawn criticism from the kidney community, members of Congress and the Medicare Payment Advisory Commission, which has suggested that CMS not implement the plan at all. The concern on the kidney community is its magnitude — the ETC model would involve more than 200,000 patients on dialysis — and while it includes financial incentives to send more of those patients home for dialysis or getting evaluated for a transplant, it also penalizes those same providers if they do not reach that goal, which was one of the criticisms of Congressional members who reviewed the plan.

Goals for ESRD, CKD care

In addition, there are bigger issues to be concerned about beyond payment incentives. By 2025, HHS wants to see 80% of the 125,000 new Medicare patients who start treatment for kidney failure each year (2016 estimates; 80% equals about 100,000 patients) to be dialyzing at home or have a transplant. That goal assumedly would be repeated each year.

Who will take care of these patients? At a time when training programs for nephrology still go empty and nephrology nurses are retiring faster than new nurses can take their place, there is a real concern about patient care.

“[American Nephrology Nurses Association] ANNA is extremely concerned that the kidney community and dialysis industry is currently unprepared for the increased number of patients that will transition to home therapy under the proposed rule,” the group wrote. “ANNA feels strongly that the current staffing model for in-center dialysis care is insufficient for the number of patients who will fail or experience complications requiring them to leave home therapy and return to in-center care at least temporarily. More importantly, ANNA fears that the proposed payment model and incentive for home dialysis therapy may stimulate the encouragement of both incident and prevalent ESRD patients to choose home dialysis when they may not be clinically appropriate or ready for this modality leading to a high failure rate.”

What about the potential for strengthening Medicare coverage of late-stage CKD care? That will require more nephrologists and nurses, just to address patients in stage 3 to 4. Remember that 37 million have some form of kidney disease, and most do not know. It will be this army of new kidney professionals that will evaluate, manage and treat these patients.

“Ultimately, the executive order and the national prioritization of kidney health would not have happened without the vision and leadership of HHS Secretary Alex Azar,” Rosenberg said during his introduction of Azar to receive the award.

That may be true, but it is time to get both providers and federal agencies on the same page.

ASN Kidney Week had the potential for a kidney care trifecta: 13,000 professionals and members of industry gathered in the nation’s capital; Medicare policymakers who regulate the $114 billion-a-year ESRD program were available for discussion; and the 4-month-old Advancing American Kidney Health, a new initiative that will likely re-shape kidney care for the next quarter century, was on the table for review.

The winning outcome during ASN Kidney Week would have been an opportunity to firm up details and get a better understanding of what the new policy would look like as the renal community makes attempts to reach the following ambitious goals of the initiative:

  • reduce the number of Americans developing ESRD by 25% by 2030;
  • have 80% 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.

ASN President Mark Rosenberg, MD, bestowed HHS Secretary Alex M. Azar II with the ASN’s President’s Medal during opening ceremonies. In his comments, Azar said, “there is no time to waste” in moving forward with developing policy to reduce kidney disease and make more kidneys available for those who need a transplant.

Much left to do

Mark E. Neumann

With a Jan. 1 deadline looming for finalizing the details of the mandatory ESRD Treatment Choices (ETC) model, Azar’s comments are on target. However, he and his team offered few answers as to its implementation date at the meeting and reaction to comments on the details of the plan.

The proposed rule has drawn criticism from the kidney community, members of Congress and the Medicare Payment Advisory Commission, which has suggested that CMS not implement the plan at all. The concern on the kidney community is its magnitude — the ETC model would involve more than 200,000 patients on dialysis — and while it includes financial incentives to send more of those patients home for dialysis or getting evaluated for a transplant, it also penalizes those same providers if they do not reach that goal, which was one of the criticisms of Congressional members who reviewed the plan.

Goals for ESRD, CKD care

In addition, there are bigger issues to be concerned about beyond payment incentives. By 2025, HHS wants to see 80% of the 125,000 new Medicare patients who start treatment for kidney failure each year (2016 estimates; 80% equals about 100,000 patients) to be dialyzing at home or have a transplant. That goal assumedly would be repeated each year.

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Who will take care of these patients? At a time when training programs for nephrology still go empty and nephrology nurses are retiring faster than new nurses can take their place, there is a real concern about patient care.

“[American Nephrology Nurses Association] ANNA is extremely concerned that the kidney community and dialysis industry is currently unprepared for the increased number of patients that will transition to home therapy under the proposed rule,” the group wrote. “ANNA feels strongly that the current staffing model for in-center dialysis care is insufficient for the number of patients who will fail or experience complications requiring them to leave home therapy and return to in-center care at least temporarily. More importantly, ANNA fears that the proposed payment model and incentive for home dialysis therapy may stimulate the encouragement of both incident and prevalent ESRD patients to choose home dialysis when they may not be clinically appropriate or ready for this modality leading to a high failure rate.”

What about the potential for strengthening Medicare coverage of late-stage CKD care? That will require more nephrologists and nurses, just to address patients in stage 3 to 4. Remember that 37 million have some form of kidney disease, and most do not know. It will be this army of new kidney professionals that will evaluate, manage and treat these patients.

“Ultimately, the executive order and the national prioritization of kidney health would not have happened without the vision and leadership of HHS Secretary Alex Azar,” Rosenberg said during his introduction of Azar to receive the award.

That may be true, but it is time to get both providers and federal agencies on the same page.