Biden administration should prioritize kidney health in first 100 days
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Kidney disease is a public health crisis that costs the federal government more than $120 billion per year and threatens to bankrupt the Medicare Trust Fund.
There are also significant health disparities in kidney disease, as historically underrepresented communities and persons with low socioeconomic status make up a large percentage of the more than 37 million adults in the United States with this disease and the estimated 80 million adults at risk of developing kidney disease.
Early detection of kidney disease, increased utilization of home dialysis therapies and increased transplantation could not only improve patient lives, but also save a substantial percentage of the costs associated with kidney disease. However, a concerted effort of policy and regulatory changes is needed to shift the dynamics of the current health care industry to prioritize these goals.
To address both the public health and fiscal crises, the National Kidney Foundation is calling on the Biden administration to combat kidney disease in the first 100 days by doing the following:
- prioritize kidney patients in the national COVID-19 strategy;
- increase federal funding for awareness, prevention and research on kidney disease; and
- focus on specific policy areas where improvement is most needed: health disparities, technology and modality choice, and transplantation.
COVID-19 vaccine
The SARS-COV-2 pandemic has demonstrated the vulnerability of patients with kidney disease. The first reported death associated with COVID-19 in the United States was a kidney patient on dialysis in Washington state.
People on dialysis tend to have numerous comorbid conditions and often require multiple trips per week to congregate in in-center dialysis facilities. As a result, they are more vulnerable to SARS-COV-2 exposure and COVID-19. According to a June 2020 report from CMS, patients with kidney failure have the highest risk of COVID-19 hospitalization among all Medicare beneficiaries.
Additionally, kidney transplant recipients must take immunosuppressive drugs to maintain and protect their transplant, and thus are at an extreme risk of infection and subsequent mortality. Data from the U.S. Renal Data System show a marked increase in mortality attributable to COVID-19 during the second quarter of 2020 among both patients on dialysis and transplant patients. Therefore, we ask President Biden and Vice President Harris to ensure patients with kidney disease have priority access to COVID-19 vaccines and strategies to minimize their risk of exposure, including availability of adequate personal protective equipment and ability to transition to home dialysis where appropriate and offer telehealth services.
Increase federal funding
Looking beyond COVID-19, we need to detect kidney disease earlier so patients can have a chance to slow its progression and potentially avoid kidney failure. Approximately 80 million adults are at risk for kidney disease, mostly due to diabetes, hypertension and cardiovascular disease. Medicare fee-for-service expenditures for non-dialysis dependent chronic kidney disease (NDD-CKD) now exceeds $65 billion annually.
Reduced mortality
With improved detection and treatment, such costs could be mitigated. Investment in cancer, cardiovascular and diabetes research led to dramatic improvements in treatment and reduced mortality in the past decade, but kidney disease research remains underfunded compared to cancer, cardiovascular disease and diabetes. While mortality for these diseases have declined substantially during the past decade, kidney disease-associated mortality continues to increase.
Recent studies, including a collaboration between the NKF and CareFirst BlueCross/BlueShield have shown early intervention and treatment can reduce hospitalizations and hospital readmissions, and can slow or stop the progression of kidney disease. For these interventions to work patients need to be aware of their risk and have access to clinical professionals who can help them manage their conditions.
The Advancing American Kidney Health initiative kicked off a renewed focus on kidney disease, and we call upon the incoming adminstration to build on its success by creating a special kidney disease fund dedicated to biomedical research, innovation activities, public awareness and other activities to combat kidney disease.
Just as increased investment has led to decreased mortality in patients with cancer, investing in kidney disease research and awareness is an important tool for fighting this urgent and expensive public health crisis.
Focus on other policy areas
Beyond the immediate need to address the COVID-19 threat and to reinvest in kidney health, the incoming administration should also tackle the following three other priority areas for the kidney community:
- address health disparities in kidney care;
- expand access to treatment modalities, such as home dialysis, and improve coordination; and
- provide transparency and accountability in the transplant system by creating an Office of Transplantation under the Secretary of the HHS.
There are significant health disparities among kidney patients of color. The risk of developing kidney failure among Black people is roughly four times higher than white people. Hispanic people are almost 1.3 times more likely to receive a diagnosis of kidney failure compared to white people and other multiracial groups. People who are Asian American and American Indian also have a higher prevalence of kidney disease than white people. Multiracial groups are at increased risk of more rapid loss of kidney function and progressing from early stages of kidney disease to kidney failure.
Black patients and Hispanic patients experience more rapid decline of kidney function than white patients. Additionally, patients who receive dialysis in areas with a largely Black population or are low-income or of lower educational attainment are less likely to have received pre-dialysis care from a nephrologist. Additionally, Black patients are less likely than white patients to be referred and determined eligible for a transplant, and are less likely to receive a transplant after being placed on the transplant wait list.
We encourage the Biden administration to focus on the social determinants of health and prioritize funding for awareness, outreach and treatment within these high-risk communities.
Dialysis at home
In-center hemodialysis remains the most frequently utilized treatment option for kidney failure. However, patients need better education about dialysis options and alternate treatment modalities, namely, home peritoneal or hemodialysis. One of the major barriers to improving the utilization of home dialysis is that patients sometimes require assistance with cannulation and other procedures. If a nurse or specialized technician could provide regular, in-home support, this would empower many more patients to successfully utilize this modality. Additionally, dialysis organizations should be incentivized to educate patients on all available modalities of care, including transplant, throughout patients’ disease trajectory. Education should be made available as early as possible, but also repeated frequently to ensure patients are able to make educated decisions as they learn better how to cope with their illness.
Transplant access
While dialysis is the most frequently used treatment, transplant is the preferred treatment option for kidney failure. Transplant frees patients from the regimen of burdensome dialysis treatment and greatly improves their quality of life by allowing them to return to normal activities.
While more than 100,000 Americans are awaiting a kidney transplant, 23,400 Americans received a transplant in 2019 and less than one-third of those transplants came from living donors. Unfortunately, the nation’s complex organ transplantation system is siloed, inefficient and lacks accountability. This inefficiency contributes to the fact that 12 kidney patients die each day awaiting a lifesaving transplant, while more than 3,500 potentially viable deceased donor kidneys are discarded by transplant centers and organ procurement organizations each year.
We ask the incoming administration to create an Office of Transplantation within the HHS to better coordinate and align the diverse and sometimes competing interests that contribute to the inefficiencies in our current system. A specific focus of this office should be to address the significant disparities facing Black and non-white patients in accessing a transplant.
Great opportunity
There is great opportunity to improve kidney care in the United States and significantly improve patients’ lives. By prioritizing kidney patients in the COVID-19 response, increasing federal investment in research and public awareness of kidney disease and focusing on three key policy areas of health disparities, technology and modality choice with transplantation, we can address the public health crisis and fiscal threat to Medicare that kidney disease presents.
It is rare to have health policy that can both save money and improve patients’ lives, but we are hopeful the Biden adminstration will seize this opportunity and prioritize kidney health in their first 100 days and throughout their administration.
- For more information:
- Paul Palevsky, MD, is professor of medicine at the University of Pittsburgh School of Medicine and chief of the Renal Section at the VA Pittsburgh Healthcare System. He is also president of the National Kidney Foundation.
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