Patient-centered, value-based care remains part of reimagining the Medicare ESRD Program
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As a teenager at camp in 1973, a looming tornado forced Dori Schatell, MS, and her fellow campers into the basement of the lodge. While waiting out the storm, counselors shared two ethical dilemmas with the teens to pass the time.
“Our counselor handed us a sheet of paper describing 12 people who needed dialysis and there were only six dialysis stations available,” Schatell, now executive director of the Medical Education Institute, told Healio/Nephrology News & Issues. “Sixteen years later, I learned that this really happened before the Medicare End-Stage Renal Disease Program passed.”
Schatell was referring to local selection committees set up in the 1960s to decide how scarce dialysis machines should be allocated for people with failing kidneys. The committees were featured in a LIFE magazine cover story in November 1962 entitled, “They decide who lives, who dies.”
While the kidney care community will never again face the need for “God committees,” as these were labelled by the mainstream press, sources that spoke with Healio/Nephrology News & Issues said that the ESRD program needs change after 5 decades.
“Has the program saved lives?” Schatell, whose company provides education materials to help patients decide on modality options, said. “Absolutely. Is it perfect? Well, no. We have a system-level challenge, and we need a system-level change to fix it.”
Cost of care
Seven percent of Medicare annual expenditures go toward treating patients with kidney disease – a little more than $37 billion in 2020. Yet the cost of the dialysis treatment is a small portion of that amount. Under the final rule for the Prospective Payment System, CMS will pay $7.9 billion to approximately 7,800 dialysis facilities in 2023 for furnishing renal dialysis services and providing kidney drugs for patients.
Source: Theodore I. Steinman, MD
Billions more are spent on hospitalizations for patients who start dialysis and are already debilitated from the ravages of chronic kidney disease, as typified by the effects of diabetes and CVD.
“Comprehensive, quality pre-ESKD care must be part of the ESRD Program,” Theodore I. Steinman, MD, professor of medicine at Harvard Medical School and senior physician at Beth Israel Deaconess Medical Center in Boston, told Healio/Nephrology News & Issues. “But there is one significant question that needs an answer before considering chronic dialysis initiation: Will the patient derive overall benefit from treatment?” Steinman, a member of the Editorial Advisory Board for Healio/Nephrology News & Issues, said. “We need to help patients make their own decisions about what level of kidney care they want, and this needs to be based on facts.”
Patient control
Changes begin with options teaching as the patient approaches ESKD, Steinman said, “We need to explain to the patient the various options of hemo- and peritoneal dialysis delivered in a home vs. clinic setting, and how to best prepare for their choice of treatment,” Steinman said. “We need to help patients maintain control of their blood pressure, achieve tight glucose control, and lower sodium intake. These are ways of achieving a participatory care approach that have an impact on outcomes,” Steinman said.
Douglas S. Johnson, MD, who is on the Board of Trustees for Dialysis Clinic Inc., said the dialysis provider, which treats 14,000 patients in the U.S., sees opportunities to improve the ESRD program.
“If we could change the benefit, people with an eGFR less than 30 mL/min per 1.73 m2 would have access to care if they are in stages 4 and 5 chronic kidney disease,” Johnson told Healio/Nephrology News & Issues. “We also think there should be an adjustment to payment for dialysis care to promote transplantation, particularly preemptive transplant so patients can avoid or minimize time on dialysis.”
Other changes Johnson suggested include adjustments to Medicare payments to discourage dialysis initiation at an eGFR greater than 15 mL/min per 1.73 m2 and to reward initiation at eGFR less than 10 mL/min per 1.73 m2.
“Adjustments to payment to encourage home dialysis, dialysis initiation without incident hospitalization, and dialysis initiation with a permanent access would also be beneficial,” Johnson said.
CMS also should offer payment for people to receive palliative dialysis care while also receiving hospice care, he said.
Older population
The quarterly update from the United States Renal Data System shows that, at the end of 2021, there were 793,658 people registered as having ESKD – most of whom are on in-center dialysis. Almost half of those patients – 346,000 – were aged 65 to 75 years and older. “End-of-life care as an option for someone who is 85 years old and has multiple comorbid conditions is not always well explained,” Steinman said.
CKD intervention
George Hart, MD, chief medical officer of Interwell Health, agrees with Steinman and Johnson that high costs for the ESRD program are reflective of patient care that lacks early intervention. Interwell Health, which recently formed after combining with Cricket Health and Fresenius Health Partners, offers health plans care management for patients with advanced CKD and is a participant in the Kidney Care Choices demonstration offered by CMS.
“If I had my chance to draw the ESRD program up, we would start with the simple premise that any program that is focused on ESKD cannot just be focused on ESKD,” Hart, who helped coordinate the practice of 80 nephrologists and advance practice providers as president of Metrolina Nephrology Associates in Charlotte, North Carolina, before joining Interwell, said. “This idea of going further upstream and doing a better job of slowing disease progression has to be fundamental to how we look at renal disease in the future.”
Key to the process is building a strong relationship with primary care physicians, Hart told Healio/ Nephrology News & Issues. “We are building a better narrative with primary care,” he said. “We need to get our arms around a plan that gets us to these patients sooner.”
While value-based care can offer health plans and patients better options in slowing the progress of kidney disease, “we are not going to be successful in slowing down the disease for everybody,” Hart said. “So, we must do a better job of improving access for patients for preemptive transplant, being able to dialyze at home, allowing them to be fathers, mothers, sisters [and] brothers, and keeping them employed.
“We want to provide kidney care where their lives are minimally impacted,” Hart said. “We can do a better job with that.”
- Reference:
- ESRD Quarterly Update, 2019 to 2021. www.niddk.nih.gov/about-niddk/strategic-plans- reports/usrds/esrd-quarterly-update. Accessed Dec. 19, 2022.
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- George Hart, MD, can be reached at ghart@interwellhealth.com.
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