Last year, President Trump signed an executive order to advance kidney health in America, which for too long has been chronically subpar. Recently, the Trump administration unveiled a major cornerstone of this vision for kidney health. These new policies will improve the quality of life for Americans on dialysis through greater access to home dialysis and kidney transplantation.
Over 37 million Americans have chronic kidney disease, and 800,000 are in the last stage of the condition, also known as kidney failure or end-stage renal disease (ESRD). Patients with ESRD can face an array of health challenges, including fatigue, confusion, difficulty breathing, swelling in the legs, and lack of appetite.
They have the number-one rate of COVID-19 diagnoses among Medicare beneficiaries, and are at the highest risk of being hospitalized with a COVID-19 diagnosis, with an 8 times' higher rate than other Medicare beneficiaries. While they make up around 1% of Medicare beneficiaries, ESRD patients' care costs approximately $35.9 billion annually, or 7% of Medicare spending.
The toll of the disease makes it difficult for patients to manage other medical conditions. As a result, many patients and their families elect to begin dialysis, which helps remove fluid and perform other life-sustaining functions that a person’s kidneys would normally carry out.
In the U.S., 88% of Medicare beneficiaries who need dialysis go to a dialysis facility, usually three times a week for three- or four-hour treatments. During the pandemic, this meant that most people with ESRD had to travel to dialysis facilities for care, increasing their risk of contracting the virus. More generally, while the majority of patients with ESRD dialyze in a center, patients who have dialysis at home have been shown to experience better quality of life and health outcomes. Our meager 12% rate of home dialysis compares unfavorably to other countries, like the United Kingdom (18%) and Canada (25%). Our system must improve for patients.
While dialysis helps manage symptoms and improve quality of life for patients with ESRD, a kidney transplant is the closest thing to definitive cure. On that front, America ranks in the bottom half of comparison countries in percentage to receive a transplant.
This all-too-often-deadly lag is largely due to a lack of available donated kidneys. Given how much lower mortality is after a kidney transplant – approximately 70% lower for those who receive a kidney versus those who remain on the transplant list at four years - it’s vital that we increase access to this critical treatment option for all Americans.
With these facts in mind, we saw two major opportunities to advance kidney health: promote choice for Medicare beneficiaries on where and how they receive dialysis and incentivize providers to work with their patients to achieve an increased rate of kidney transplants.
That’s where this announcement comes in. The Centers for Medicare & Medicaid Services (CMS) has released a new model that changes how we pay for kidney care. The approach, which is being tested in certain parts of the country, works by increasing payment for home dialysis services and tying how much we pay for other care to providers' performance on home dialysis, transplant wait-listing, overall rates of living donor kidney transplantation, and other important metrics. CMS is also expanding payments to providers to educate beneficiaries on ESRD treatment options, nutrition, and their overall care management. In short, the model incentivizes home dialysis and kidney transplantation by tying CMS payment to how many patients receive those services.
CMS is also leading learning across the nation to share best practices about how to ensure more donated kidneys are transplanted. This builds on earlier changes to our regulations that encouraged improved donation rates for all organs. Taken together, these measures represent a watershed moment in kidney care. Patients deserve a real choice in the treatment they receive for their kidney disease. These actions will give it to them.
We have coordinated these policies with a sister agency, the Health Resources and Services Administration (HRSA). HRSA has announced a rule expanding support for living organ donors, who predominantly donate kidneys, helping to reimburse living donors for childcare costs and eldercare along with lost wages while they are going through the selfless process of organ donation.
Dialysis facilities and clinicians managing dialysis patients have been working tirelessly throughout the public health emergency. But the need to focus on advancing kidney care through greater rates of home dialysis and kidney transplants is more apparent than ever. That’s exactly what President Trump has done. With this initiative, he is improving the quality of care Americans receive, and the health of our nation, by tackling longstanding problems in our healthcare system.
Seema Verma is administrator, Centers for Medicare and Medicaid Services (CMS).
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