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Evaluate the risks and rewards of Advancing American Kidney Health
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When speaking at a press conference just hours before President Trump unveiled the Advancing American Kidney Health initiative, HHS Secretary Alex M. Azar II called the package of new regulations and financial incentives “the most significant initiative undertaken on kidney disease by any President, and the single biggest change to how we treat this disease since Medicare began covering end-stage renal disease patients in 1973.”1
Shep Glazer, who created one of the most dramatic moments of patient empowerment in the history of health care policy in 1971 when he sat with a dialysis machine on the floor of Congress, might concur with that statement. He was part of a group of patients who persuaded Congress to fund the Medicare ESRD Program, eventually saving the lives of thousands of people destined to die from uremic poisoning. Today, it has mushroomed to providing care for more than 700,000 patients and generates annual expenditures for Medicare of around $34 billion annually, including treatments, drugs and hospitalizations.
It is too early to determine if Advancing American Kidney Health will have the impact of the 1972 legislation. Certainly, there is a great deal of potential. It sets the following specific, ambitious goals:
- reduce the number of Americans developing ESRD by 25% by 2030;
- reduce the number of Americans receiving dialysis in a dialysis center, from 2019 levels, by 80% by 2025, and
- double the number of kidneys available for transplant by 2030.
“Under the umbrella of this initiative, we’re going to use every tool we have, across HHS, to deliver better health for kidney patients,” Azar said.
There is an acknowledgement, with incentives offered, that more aggressive treatment of kidney disease in its early stages may prove beneficial for patients, caregivers, and the cost of the Medicare ESRD Program long-term. That will be accomplished, HHS hopes, with new payment models which would place more than 200,000 dialysis patients in a demonstration and “offer new incentives to prevent the progression of kidney disease and manage kidney patients’ health in a more comprehensive and person-centered way,” Azar said.
The first is the ESRD Treatment Choices Model, which would be mandatory for 50% of patients on dialysis and provide bonus payments to dialysis providers for having more patients take up home dialysis and show an increase in transplantation rates. Two other voluntary models — Kidney Care First and the Comprehensive Kidney Care Contracting model — require participation by only nephrologists and transplant providers with other participants, including dialysis facilities, optional. The Kidney Care First model would create a monthly capitated payment (MCP) for CKD care in addition to the current ESRD MCP and offers bonuses for nephrologists with patients receiving kidney transplants.
The ESRD Treatment Choices payment model has been released as a proposed rule and is out for review (visit www.regulations.gov to find the proposed rule and offer comments); details on the other payment models were scheduled to be provided by the end of August when HHS was expected to open a request for applications.
Through public-private partnerships, HHS will support the development of artificial wearable and implantable kidneys and place a greater emphasis on educating patients about modality choice.
In this month’s issue of Nephrology News & Issues, we asked Benjamin E. Hippen, MD, FASN, FAST; Jeffrey Giullian, MD, MBA, FASN; and Brent W. Miller, MD, to share their views on the potential of the Advancing American Kidney Health initiative to increase transplant rates, improve the CKD-ESRD treatment approach and determine whether home dialysis can become the predominant dialysis therapy during the next 6 years.
Models with financial incentives can help steer this initiative in the right direction. More importantly is whether it is the direction that patients want to go and if so, can nephrologists and providers move it forward? It won’t take until 2025 to find out.