Trump Signs Order to Increase Kidney Donation, Home Dialysis

Kerry Dooley Young

July 10, 2019

WASHINGTON — The Trump administration on Wednesday outlined initial steps for reshaping how the federal government pays for care of end-stage renal disease (ESRD), including efforts to encourage home-based dialysis and donation of kidneys.

President Donald J. Trump signed an executive order that tasks the US Department of Health and Human Services (HHS) with developing a series of proposals for addressing kidney disease. As part of this effort, HHS on Wednesday unveiled a proposed rule for testing how changing Medicare's approach to paying for end-stage renal disease might deliver better results for people with this condition.

The HHS proposals should prompt a "long overdue" change in Medicare's policies, said Matthew R. Weir, MD, a professor of nephrology at the University of Maryland School of Medicine in Baltimore. They now tilt too often in favor of keeping people on dialysis instead of seeking to help them secure kidney transplants, he told Medscape Medical News.

"If they change the reimbursement, for example, so the nephrologists get compensated the same for managing a kidney transplant patient as they do for dialysis, we would see a lot more people getting kidney transplants," Weir said.

"And if they improved the compensation for nephrologists to take care of more home hemodialysis patients, you'll see a change," he added.

By taking on end-stage renal disease, HHS is addressing an aspect of the US medical system in which there already is in effect something akin to the Medicare-for-all proposals put forth by many Democrats.

Since 1973, Medicare has covered people of all ages who have end-stage renal disease. That has made it the dominant payer in a field where care has proven costly.

In a recent regulatory filing, DaVita Inc, one of the largest for-profit dialysis companies, said that 75% of its patients getting this medical treatment in 2018 were covered by Medicare. The program in 2017 paid $11.4 billion for outpatient dialysis services for almost 395,000 people, according to the Medicare Payment Advisory Commission (MedPAC).

"There may be no better example than kidney care of how government domination of healthcare can sideline patients, discourage innovation from providers, distort payment incentives, and focus only on paying for treating sickness rather than preventing disease and supporting health," said HHS Secretary Alex Azar in a statement.

The annual cost for Medicare from kidney disease, including both chronic and end-stage forms, is more than $114 billion, according to the US Renal Data System's 2018 Annual Data Report. Kidney disease compounds the expenses of caring for people with diabetes and heart failure, serving as a cost multiplier, the report states.

Alternative Payment Models

In its new effort, the Trump administration is seeking to make the public more aware of the risks of kidney disease, as well as mulling changes in payment for care of advanced cases.

The Centers for Medicare & Medicaid Services (CMS) intends to run four optional tests of alternative payment meant to improve care of people with kidney disease. These tests may involve more than 200,000 people enrolled in Medicare.

The payment tests include a planned "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," Azar said in the statement.

But HHS also plans to compel participation in another test, known as ESRD Treatment Choices (ETC), Azar said. This mandatory payment model is intended to give about half of all dialysis providers new incentives to encourage dialysis in the home.

"This means about 50% of Medicare patients with kidney failure will be able to benefit from the expanded options encouraged by this model, with the support and education they need to benefit from them," Azar said.

In the draft rule released Wednesday, CMS and HHS proposed to implement payment adjustments through the ETC Model over the course of 6.5 years, beginning January 1, 2020, and ending June 30, 2026.

The proposed test would include two payment adjustments. The Home Dialysis Payment Adjustment would be a positive adjustment on certain home dialysis and home dialysis-related claims during the initial 3 years of the model.

The Performance Payment Adjustment would be a positive or negative adjustment on dialysis and dialysis-related Medicare payments, for both home dialysis and in-center dialysis, based on ESRD facilities' and managing clinicians' rates of kidney and kidney-pancreas transplants and home dialysis among attributed beneficiaries, the draft rule states.

In announcing the new initiatives, HHS set ambitious goals, including reducing the number of Americans developing end-stage renal disease by 25% by 2030. Azar also spoke of reducing the number of Americans receiving dialysis in a dialysis center — from 2019 levels — by 80% by 2025, and doubling the number of kidneys available for transplant by 2030.

"A Renaissance"

It's unclear how far HHS will proceed with its efforts. Still, the Wednesday announcement drew praise from many organizations in the nephrology community.

"Kidney care is, for the first time in decades, experiencing a renaissance that can transform the lives of millions of Americans while also saving taxpayers billions of dollars," said Kevin Longino, chief executive officer of the National Kidney Foundation and a kidney transplant patient, in a prepared statement.

In a statement provided to Medscape Medical News, Javier Rodriguez, chief executive officer of DaVita, said the company was "encouraged" by the HHS plan.

"We have pushed for progressive policies to give all patients access to integrated kidney care, the benefits of which are significant to our patient population. Educating patients about kidney disease is critical to prevention and slowing its progression," Rodriguez said. "Early intervention leads patients who may still need dialysis to choose the best treatment option for their lifestyle and reduces expensive hospitalizations."

DaVita has for many years invested in home dialysis, including use of remote monitoring. This allows patients to utilize Bluetooth devices to transmit vital data to their physician, and telehealth for on-demand remote visits.

"In partnership with nephrologists, we are best positioned to deliver in the home dialysis space, as the largest provider of home dialysis in the U.S.," Rodriguez said.

In presenting the new initiative, Azar told of his own father's experience with renal disease.

A physician, Azar's father saw his kidneys weaken to the stage where he needed dialysis several times a week, a "draining" experience, the HHS secretary recalled. His father then learned he could switch to peritoneal dialysis, allowing him to undergo treatment at night in his home.

"Then, we were blessed that he was offered a kidney transplant from a kind and generous living donor," Azar said. "My father's story has a happy ending, and we know he was lucky. Too many Americans don't know about or aren't supported in shifting to more convenient dialysis options, and too many Americans never get a chance at a kidney transplant."

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