Chronic kidney disease kills more people than breast or prostate cancer each year, but you won’t see NFL players wearing socks and gloves to increase awareness, or massive fun runs raising money to treat it. According to the National Kidney Foundation, 37 million people in the U.S., or 15 percent of adults, are impacted by CKD, and around 90 percent of those with the disease don’t even know they have it.
The costs of kidney disease are unsustainable. Medicare paid $114 billion for people with all stages of renal disease in 2016, which was nearly 20 percent of all Medicare spending that year. It includes $23,558 per person for someone with non end-stage kidney disease, which is twice the spending for the average Medicare beneficiary, according to the National Kidney Foundation. In 2016, Medicare spent $89,000 per dialysis patient and $35,000 for kidney transplant patient. While just one percent of Medicare beneficiaries have kidney failure, kidney failure accounts for over seven percent of all Medicare spending.
But an executive order signed by President Trump this summer could change the way kidney disease is treated in the country. With the lofty goal of reducing the number of people with final stage renal disease by 25 percent by 2030, the policy focuses improving prevention and education, effective and convenient treatment, and increasing the number of kidneys available for transplant.
Dallas Nephrology Associates CEO Dr. Alexander Liang says that one of the reasons CKD is so under-recognized is because there is no pain or outward signs for most of the time with the disease. He says it sometimes is not as much of a priority for primary care physicians, as the lab values are often not urgently alerting. But with a disease that impacts such a large portion of the country, Liang welcomes what the executive order could mean for the kidney treatment and overall healthcare costs.
Kidney disease is caused by high blood pressure and diabetes, and is treated through dialysis, which removes toxins from the blood. Another option is a kidney transplant. Too often, Liang says, physicians and patients aren’t aware of the problem until the disease is in its late stages, where costly dialysis or transplants are the only options. By 2030, the order says, there should be a 25 percent decrease in end stage kidney disease patients. Education and awareness will play a big role in meeting that goal.
The executive order lays out a policy for the Department of Health and Human Services to begin a public awareness campaign about the disease, and for the Centers for Disease Control to improve kidney disease tracking. Medicare payment models are also incentivizing education and prevention are part of the plan.
At Dallas Nephrology Associates, one of the three largest nephrology practices in the country, a series of classes and programs help patients learn about the disease, treatment options, and how lifestyle choices can improve or hurt the kidney. “We are making sure people understand the changes they need to make to prevent the progression,” Liang says.
Another piece of the executive order emphasizes less costly and more convenient treatment, which often means home dialysis. Home dialysis is much cheaper for the medical system, which is usually paid by Medicare for patients with kidney disease. With equipment that can be used at home, fewer staff and facilities are needed. According to Modern Healthcare, in-center dialysis treatment costs $256 per patient, while only costing $215 to deliver the same care at home in 2017. Liang says it is about building confidence of the patients, who are often overwhelmed and nervous about the equipment.
It is also much more convenient. Dialysis can take several hours, and reporting to a hospital or dialysis center three times a week for four hours can prevent a patient from working, traveling, or living their lives. Peritoneal dialysis can even be done at night at home while the patient is asleep.
Liang says the rate of at home dialysis is about 12 percent right now, but that executive order is a good first step to move more patients to their home. It says that by 2025, 80 percent of patients starting dialysis should start at home or get a kidney transplant. There is some debate about whether the dialysis mammoths DaVita and Fresenius are on board with the move toward at home dialysis, as an empty chair in a center means less income for them. The companies say they are all in on at home dialysis, but CVS Health is also entering the market for home dialysis, which could be a major disruptor and could increase the move to at-home care.
By 2025, the policy says the number of kidney transplants in the US should double because transplant is a less expensive than years of dialysis. Increasing donors is also about education, letting people know about the low risks for donors and recipients alike. One key point, Liang says, is that recipients of kidney transplants can lose their Medicare coverage after receiving transplant. An extension of coverage could increase transplants. Also, added benefits for donors such as making sure they don’t lose time at work or that the surgery doesn’t count against them on their insurance are other measures that may increase kidney transplants.
Sharing the risk is also a way to innovate and save costs treating kidney disease. At DNA, which sees 10 percent of patients on dialysis in the entire state, Liang says they have created an ACO for dialysis patients, where they share some of the risk for the patients’ cost. Partnering with dialysis provider Fresenius, the practice was able to educate patients, divert emergency room visits and ended up saving $5 million in 2016 alone. Reducing hospital readmission with care navigation and transportation vouchers were also part of the cost reducing measures.
“If you look at medicine in general, we need to be able to coordinate care, between primary care and specialists, specialists and specialists, dialysis units and doctors, and doctors and hospitals so they can integrate and share information,” Liang says. “The system is going to collapse. There are not enough dollars to support the growth of dialysis.”
Liang says the practice knew that CMS would soon mandate these cost sharing measures, so they have been getting ahead of the requirements. While the details about the policy have yet to be determined by HHS, getting in this mindset will hopefully pay dividends in the future. “We knew that this would eventually coming down the pipe,” he says. “We have made a lot changes in our practice, so we have the infrastructure to do it now.”