The order identifies three goals of the regulatory reforms: prevention through better education and awareness, innovation by encouraging treatment alternatives such as artificial kidneys, and modernization of the kidney transplant system.
The National Kidney Foundation says kidney disease is the ninth-leading cause of death in the United States. It affects approximately 15 percent of the U.S. adult population—more than one in seven adults—and is a silent killer. Approximately 90 percent of people with the disease don’t know they have it until they are in the late stages of illness. In 2016, more than 500,000 patients in the United States received dialysis treatment, and more than 200,000 were living with a kidney transplant.
Kidney patients of any age qualify for coverage under Medicare, and today it is one of the program’s biggest cost drivers at $114 billion a year.
Although previous presidents have taken steps to foster better detection of the disease and increased access to transplants, President Donald Trump’s July 10 executive order marks the first time since the 1970s that the White House has addressed kidney health as a whole, says Paul Conway, past president of the American Association of Kidney Patients and a kidney transplant recipient.
“This is a bold, forward-looking policy that changes a landscape that’s been largely untouched,” said Conway. “It’s a clarion call of optimism to those who suffer from kidney disease and to those who may yet be diagnosed. Kidney disease does not have to be a death sentence.”
Excessive Reliance on Dialysis
Conway, who was at the White House when Trump made the announcement, says kidney treatment has been a victim of its own success.
“Dialysis was originally intended to be a bridge to transplantation, but it has been so effective that it often becomes the end goal in itself,” said Conway.
“As a result, the medical field has lost sight of its constant drive for improvement and ingenuity in treating the disease,” said Conway. “Unleashing the free market and increasing patient options is key to better care, and President Trump’s executive order does just that.”
Chad Savage, M.D., a practicing physician and policy advisor to The Heartland Institute, which publishes Health Care News, says he is hopeful the executive order will increase the availability of care and patients’ options.
“Currently, a few large companies dominate the hemodialysis world and make it challenging to get good pricing on these services,” Savage said. “If the administration is able to incentivize competitors into this market, the additional competition should help moderate pricing and improve service.”
Congress on Board
Congress is currently considering legislation reflecting the goals the president laid out in his executive order.
The Living Donor Protection Act would help increase the availability of kidney transplants by prohibiting insurance companies from denying or limiting donors’ coverage because of a preexisting condition and prevent them from charging such patients higher premiums.
The Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act would ensure transplant recipients have lifelong access to immunosuppressive medications beyond the 36-month supply Medicare currently covers.
In addition, the U.S. Department of Health and Human Services (HHS) is setting up new payment models for kidney treatment through the Centers for Medicare & Medicaid Services.
Whereas the current Medicare system offers in-center dialysis as the default option for newly diagnosed patients, the new plan will set up incentives to encourage home dialysis, less-intrusive treatments, and transplants.
“Within that set of models, there is one pathway for nephrologists to receive bonuses for keeping patients healthy, and three models for local entities to take on different levels of financial risk for the health of their patients,” said HHS Secretary Alex Azar.
In compiling the final rules, the administration should avoid policies that interfere with the doctor-patient relationship, says Savage.
“One cautionary aspect of Secretary Azar’s comment is that he described linking financial harms to physicians based on outcomes of their patients,” said Savage. “Though in concept this sounds good, it could result in doctors avoiding some of the sickest or most challenging patients to protect their bottom line. “Challenging patients still need care.
“Also, [Azar] mentioned trying to dictate treatment plans through the payment model, which is a decision that should largely be left to the patient and the doctor and never be the purview of billing and coding systems, which, even if well-constructed, will always lag behind medical advancements,” said Savage.
Despite these concerns, the executive order is good news, says Savage.
“Addressing the significant burden of kidney disease in the United States is very important, and it is excellent news that this administration has decided to confront this challenge,” said Savage.
Addressing Costs, Cures
Physician Elaine Habig, M.D., says the executive order will help address the current deficiencies of kidney care.
“As a practicing internist of 49 years, I have past and current patients with transplants, home dialysis, and strip mall hemodialysis,” said Habig. “I also have numerous others who refuse to change behaviors, and fully expect that if we continue to reward bad behavior, those numbers will grow.
“The cost of health care is so high in the U.S. because current policy rewards care that keeps people sick, not well,” said Habig. “Patients need more skin in the game. Most kidney disease is preventable,” said Habig. “Obesity is delivering life sentences of kidney failure through high blood pressure and diabetes starting at early ages.”
Madeline Peltzer ([email protected]) writes from Hillsdale, Michigan.
Executive Order on Advancing American Kidney Health, The White House, July 10, 2019: https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/