Misaligned payment policies hurt efforts to develop innovative kidney care solutions
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In the pursuit of progress in patient-centered kidney care, it is essential to recognize the vital role that access to innovation plays in providing hope to people battling kidney disease.
Newly approved treatment options need to have adequate time to be understood and adopted by physicians. Stable coverage, reimbursement certainty and opportunity all need to be part of the payment plan to improve quality of life and well-being for patients.
However, the Prospective Payment System, which pays for dialysis services with a bundled payment per treatment, is failing to align with patient-centered principles. That stifles the prospect of innovation, compromising the well-being and future of those who need it most.
The Cover Story in the October 2023 issue of Nephrology News & Issues highlighted the important strides in developing bioartificial kidneys and the use of xenotransplantation to alleviate organ shortage. But there are dire consequences that arise when patient access to innovation in dialysis care is neglected and the significance of prioritizing hope in health care is pushed aside.
‘Average patient’
Most recently, members of the U.S. House wrote a letter to CMS Administrator Chiquita Brooks-LaSure expressing concern about how the dialysis payment bundle is deterring innovation (see National, page 5). Bundled payments, while aiming to streamline costs and improve efficiency, stifle access to cutting-edge therapies and new treatment options that can improve well-being. By limiting reimbursement solely to a fixed bundled amount designed for the “average patient,” this system discourages health care providers from pursuing individualized, innovative approaches, leaving patients devoid of hope and restricted to conventional treatments, even when breakthrough options are available.
Here are some examples on how payment drives practice and how misaligned payment policies in dialysis can derail innovation.
- For one patient on hemodialysis to have access to a breakthrough treatment for pruritus, a dialysis provider would get a $0.09 increase in the base bundled payment rate. But it takes 1,500 patients on hemodialysis who do not require the drug to attain that rate. Small providers will lose money if they provide the drug to only one patient, leaving it cost prohibitive. The bundle base rate adjustment rewards providers who do not give the drug. Money should follow the patient who needs the treatment.
- Currently, the transitional drug add-on payment adjustment (TDAPA) and the transitional add-on payment adjustment for new and innovative equipment and supplies (TPNIES) from CMS only have a 2-year promise of reimbursement to encourage innovation in the dialysis space. To force innovation to be reliant on this 2-year window is unrealistic and a deterrent to innovative therapies and technology reaching the patient to improve care. The end-stage kidney disease payment system must provide long-term payment mechanisms that adjust the bundle when new products become available.
Funding innovation
The federal initiatives of Advancing American Kidney Health, Kidney Health Initiative, Kidney Innovation Accelerator and Kidney X were created to spur innovation for patients with kidney disease. Specifically, the goals are to detect and slow the progression of kidney disease, provide patients who have kidney disease with options for treatment and increase organs available for transplant. These initiatives provide hope for patients knowing that competitive merit-based cash prizes for innovators were being offered to accelerate the development of drugs, devices, biologics and other therapies across the spectrum of kidney care. Now, these federal initiatives are in direct conflict with the bundled payment model.
More patients with ESKD are joining Medicare Advantage-managed care plans – in the 2021 open enrollment period, the share of Medicare beneficiaries with ESRD enrolled increased from 22.7% to 30.3%. According to the Medicare Payment Advisory Commission, the share increased to 41% of all Medicare patients with ESRD by the end of 2021.
Medicare Advantage-managed care plans have no mechanism to provide innovation for patients. This shift within payment models will further erode access to innovation as device manufacturers will see an unstable, declining market with few incentives to invest in technology.
This misalignment of payment policies is having disastrous results. Without access to innovative treatments, patients face limited prospects for improved outcomes, enhanced quality of life and prolonged survival. Crucially, innovation holds the potential to revolutionize patient care, offering new and effective strategies to combat the challenges presented. Denying patients the chance to explore these avenues denies them the right to hope for a better future – a fundamental pillar of patient-centered care.
Challenges of kidney disease
Hope is not a mere abstract concept but an essential component of health care, serving as a source of motivation, strength and resilience for patients navigating chronic diseases like kidney disease. For patients and their loved ones, hope can provide the psychological and emotional foundation necessary to withstand the challenges that lie ahead. By ensuring access to innovative treatments, health care providers can instill a sense of hope in patients, empowering them to fight and envision a future unburdened by the limitations of their condition.
Innovation also transforms the landscape of health care, opening doors to groundbreaking breakthroughs, enhanced therapies and improved patient outcomes. From novel medications and precision medicine approaches to advanced surgical techniques and regenerative therapies, the realm of innovation in kidney disease can be as vast and promising as oncology, neurology and other areas that are seeing exciting advancements in treatments.
By embracing and fostering a culture of innovation, health care providers can proactively address unmet needs and restore hope to their patients.
It is critical that our nation incentivize innovation so we can continue to push the boundaries of what is currently possible and maintain our global competitiveness. Innovation in health care can also help attract doctors to choose nephrology as their specialty. It provides physicians with access to advanced technology, advanced medical treatments and opportunities for research and development. Additionally, health care professionals who are passionate about improving patient care and outcomes are more likely to be attracted to disease states that focus on innovation and offer cutting-edge advancements in health care.
Patient-centered approach
Health care systems should be unwavering in their commitment to a patient-centered approach, acknowledging the necessity of hope and access to innovation for patients battling kidney disease. The current ESRD bundled payment program has no sustainable means to incentivize and improve kidney care.
Misaligned payment policies risk perpetuating a cycle of limited options, denying patients the chance to explore cutting-edge treatments and stifling the potential for improved outcomes.
By promoting innovation, it helps ensure equitable access to revolutionary therapies, health care providers can weave a tapestry of hope for patients that extends far beyond their present circumstances. It is our collective responsibility to bridge the gap between payment policies and patient-centered care, enabling a future filled with hope and better health for all.
- For more information:
- Lori Hartwell is the CEO of the Renal Support Network, an advocacy group and member of Kidney Care Partners. She can be reached at lori@rsnhope.org.
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