This article is more than 5 years old. Information may no longer be current.
Azar: Outdated Medicare payment system hurting kidney care
Click Here to Manage Email Alerts
Saying that the payment system for the Medicare ESRD Program is “outdated” and “has some of the worst incentives in American health care,” HHS Secretary Alex M. Azar II announced on March 4 that the agency is developing new models that encourage a shift from paying for sick patients to one that focuses on improving outcomes, including use of more home dialysis, expanding financial incentives and access to organs for kidney transplantation, and a push for earlier detection and treatment of kidney disease.
“Today, I want to lay out what it would look like to pay for kidney health, rather than kidney disease — and pay for Americans with kidney disease to actually get good outcomes, rather than the endless, life-consuming procedures that you all know so well,” Azar said during the NKF’s Annual Kidney Patient Summit. Although Medicare covers most patients with kidney failure, “we don’t begin spending a great deal on these patients until they’re already sick. It is the epitome of a system that pays for sickness rather than health, and this administration is intent on shifting these priorities,” Azar said.
Cost of kidney care
Azar, whose father was on dialysis before getting a kidney transplant, said kidney disease is becoming a bigger part of the health care burden in the United States, with more than 30 million Americans having some stage of kidney disease — “almost the population of the state of California,” he said. In 2016, kidney disease was the ninth leading cause of death in the United States. “One hundred thousand Americans begin dialysis each year, and one in four of them are likely to die within that same year,” he said. Medicare spent $79 billion to cover people with kidney disease that year and spent $34 billion on patients with ESRD, adding up to $113 billion in total spending. “Even at this tremendous cost, what kidney patients endure is grueling,” he said.
If HHS can shift its reimbursement models to focus more on pre-dialysis care, he said, care givers will “have more time to educate patients, help them make informed choices about their treatment options, and prepare them for treating kidney failure as they wish — if and when that becomes necessary.
“This extra time allows an optimal start for treatment, whether that’s a pre-emptive transplant without dialysis, starting home dialysis with a functioning catheter or starting peritoneal dialysis with a safe, permanent access,” he said.
Send more patients home
A lack of payment incentives is hurting the chances of patients who might benefit from home dialysis, Azar said. The roughly 12% of Americans who are on home dialysis is “the complete opposite of the situation in some of our peer nations,” Azar said. “Improving this situation dramatically, as we ought to do, will mean examining the payment incentives in our programs today, while expanding access to new technologies.”
Today’s payment policies also bias providers toward center-based dialysis, Azar said.
“For one, we believe we may simply underpay for these alternatives, even though we know how much they can benefit patients’ lives. It’s also more appealing for a dialysis company to add patients to a center where one machine can accommodate multiple patients than it is to provide new services to each patient at home. But that isn’t providing the care patients deserve, and we have the power within HHS to test out significant payment changes to boost home dialysis.”
Azar said disincentives also exist for patients who want a kidney transplant. “One key step is, again, reorienting our payment incentives. Today, dialysis companies are actually disincentivized from helping patients get ready for and find a transplant. Even though a transplant improves health and dramatically lowers the cost of care, from the perspective of a dialysis company, every transplant is one less customer.
“A system that pays for health, as we envision for all of health care, will pay for the healthiest possible outcomes. Ideally, we’d want to offer dialysis providers incentives to get patients off dialysis through transplants. We want to make the outcome that’s good for the patient and good for the system good for their business, too,” he said.
In prepared statements, professional associations and industry groups responded to Azar’s comments.
“Secretary Azar’s passionate commitment to helping kidney patients, especially ESRD patients who need dialysis or a transplant to survive, is both significant and encouraging,” Kevin Longino, CEO of the NKF and a kidney transplant patient, said. “The U.S. Department of Health and Human Services is clearly charting a path towards making progress in prevention, early detection, treatment, research and access to transplantation; all critical issues for kidney patients, and they are doing this in a strategic, thoughtful and expedited way,” Longino said.
HHS Secretary Alex Azar (left) with NKF CEO Kevin Longino at the Annual Kidney Patient Summit.
Arvind Rajan , CEO and co-founder of Cricket Health, a kidney care provider startup, said, “[W]e’re excited to see CMS embracing new payment models that help address the overwhelming cost of kidney care. To really improve care for patients and control overall costs, we need to ensure that economic incentives for providers and payers alike are all focused on slowing the progression of kidney disease and keeping patients out of in-center dialysis.”
In a statement from the American Society of Nephrology, its president Mark E. Rosenberg, MD, FASN, said, “I commend the secretary and this administration for acknowledging that the current state of care for kidney patients is unacceptable and that complex barriers inhibit innovation — and for developing a visionary strategy to change that reality. Americans living with kidney diseases deserve better, and the course Secretary Azar outlined today is an exciting first step towards achieving that goal.”
References:
www.asnonline.org/about/press/releases/ASN_PR_20190304_AZARFINALstatement.pdf
www.kidney.org/news/hhs-secretary-azar-speaks-transforming-kidney-care-kidney-patient-summit