An opportunity to lead the future of ESKD care
We sit at a tipping point in the history of kidney care. This moment in time shares similarities to the early days of dialysis in the United States just before Medicare guaranteed coverage to patients with ESKD in the early 1970s.
A paradigm shift is about to occur.
The Medicare Board of Trustees’ 2019 report projects that Medicare Part A, which covers payment to hospitals, will become insolvent in 2026. In this context we are beginning to see a major shift in CMS messaging toward its approach to dialysis care with its accompanying high costs (kidney care has historically occupied a disproportionate share of the Medicare budget compared with the number of patients treated).
At the American Society of Nephrology’s Kidney Health Initiative held in May, Adam Boehler, director of the Center of Medicare and Medicaid Innovation, stated that CMS has a goal of having 80% of incident patients with ESKD begin care with a preemptive kidney transplant or a home dialysis therapy by 2025. This goal was reiterated on July 10 with the release of the executive order, “Advancing American Kidney Health” by the Trump Administration (see National, page 7). Part of the initiative is aimed at increasing the number of patients on home dialysis or having a kidney transplant. The true fraction of patients eligible and appropriate for the above approach likely varies from practice to practice, but it is almost certainly higher than the current reality in most settings.
With the new Executive Order, the kidney community will be working with policy changes and interventions in support of a kidney transplant and home dialysis preferred approach. Physician leadership and buy-in will be key to ensure the highest quality patient care is achieved during these changes, which presents both a challenge and an incredible opportunity to practicing nephrologists.
Save perhaps a lucky few, each of us in practice knows the granular detail of why preemptive kidney transplant and home dialysis are hard to implement in our system. The lack of living donors, the busy transplant centers with overwhelmed logistics, the “crash” dialysis start, the surgeon who will not place a PD catheter in the hospital, the lack of nurses to immediately train a patient on home hemodialysis or PD, the frail patient without a caregiver, and the misaligned financial incentives favoring in-center hemodialysis is a good list to start with.
On the other side, if conservative care is not being pursued, most nephrologists consistently say the same thing about what they would want for themselves or a loved one if faced with ESKD – a kidney or dialysis at home. These options offer the best outcomes, autonomy and flexibility to allow for life outside medical care, and this is why most of us say we would choose them.
Seated at the same table
Given this, these challenges of our current world are ours to own and overcome. We are being handed an incredible gift by CMS that will allow us to reshape dialysis care for decades to come – a gift most of the current generation of early practice nephrologists have never had as the broad outlines of our dialysis care system have locked us in place for more than 45 years.
With this gift comes great responsibility. We must each undergo a mind shift so in every encounter we ask ourselves, “Where is the kidney?” and if we do not have one, “Let’s get you home if it’s safe.” This will not be easy. We each have optimized our practices in a way that works for us, we know who to call and we know how to get things done efficiently. Changing this means not only changing our own behavior. It means influencing and changing the behavior of those who are outside of our direct control. It means not only guiding care inside the exam room but outside of it as well.
Put yourself in the shoes of the early pioneers of chronic dialysis in the United States. Resources were scarce and there was limited to no financial support for dialysis care. Panels needed to decide who with ESKD would live and who would die. To get care for all who needed it, those nephrologists needed to stand up and do something that was not easy. They needed to radically change not only what occurred in their exam rooms but what occurred outside of them. For this generation of nephrologists, we are now at our tipping point. We have seen what the current system produces. Time to lead and push on the balance for our patients.
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- Graham Abra, MD, is a clinical assistant professor in the division of nephrology at Stanford University, medical director of WellBound San Jose and director of medical clinical affairs at Satellite Healthcare in San Jose, California.
Disclosure: Abra reports no relevant financial disclosures.