Industry Voices—COVID-19 must reshape kidney care for the long term

We are in the midst of a public health emergency, and it has become clear that the COVID-19 pandemic is not going away in the coming weeks, or maybe even months.

It has also become clear that those with comorbidities such as kidney disease are at an increased risk for serious complications from the COVID-19 virus. The two first COVID-19 deaths in the U.S. were patients at an outpatient dialysis clinic, and early data from a hospital in Washington state show that nearly half of the COVID-19 patients admitted to the ICU had kidney disease.

In cases reported to the Centers for Disease Control and Prevention for which information was available about patients’ underlying conditions, 71% of persons with reported chronic kidney disease (CKD) were hospitalized. Further elevating this risk, more than half of Americans living with kidney disease are also managing another chronic condition.

To save lives, it is essential that we act quickly to create a new normal for kidney care. We need to do everything possible to keep those living with kidney disease healthy, at home and out of the clinic or inpatient settings whenever possible, even beyond this viral pandemic. 

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To achieve this goal, I believe there are three major changes that need to happen right now: 

First, we must educate patients about their disease, treatment options and personal risk factors related to COVID-19 as well as other complications. It’s the unfortunate truth that 90% of those living with CKD are not aware they have it, and many patients “crash” into dialysis via an ER visit.

If patients are not even aware of their condition, then they cannot effectively manage it to avoid ER visits and hospitalizations. Well-informed patients are empowered to make smart healthcare decisions, such as coordinating one trip to the lab or pharmacy for all of their needs, or, better still, arranging direct mail for their prescriptions or in-home sample collection for labs.

Studies have also shown that when patients understand their treatment options, they are more likely to choose at-home dialysis, which can reduce COVID-19 exposure in the short term and be much more convenient and cost effective in the long term. As we face this pandemic, it’s essential that we shift end-stage renal disease (ESRD) treatment away from dialysis clinics, and doing so means educating patients on this option, guiding them through the transition and supporting them through the new treatment.

For those new to dialysis, providers can encourage this choice, but for those moving to home-based treatment, this may require a thoughtful change in payer policy to reimburse assisted modalities. We also need to rethink how and where we train patients and maximize training steps that can be done safely in the home. 

ESRD treatment is only the beginning, though; the second change we must make is transitioning to a home-centric approach throughout the kidney care spectrum.

This poses a challenge, as many kidney patients require frequent care and support, and those needs continue during the pandemic. However, just as we’re seeing a rapidly evolving ecosystem of telehealth, virtual care and remote monitoring across healthcare, we too must leverage these solutions in kidney care. Nephrologists, primary care physicians and others on these patients’ care teams can take advantage of the landscape of tools to continue offering patient-centered, high-touch care that maintains patient health throughout this crisis, not to mention limits providers’ own exposure to risk.

Lastly, if we are to ask providers to implement these changes, we must remove the regulatory obstacles holding them back and ensure they are fairly compensated for these newly adopted services. To date, the federal government has moved swiftly to do this.

Medicare is now reimbursing nephrologists, nurses and other practice staff for dialysis and other kidney care delivered via telemedicine, including phone call check-ins. This is essential to minimizing disruption to patients’ regular care and maintaining their stability, and it’s important that private payers follow this lead. That being said, these rules are temporary, and we should not only grant patients this access to care and providers these resources during the height of an epidemic.

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Virtual care is an essential part of a better kidney care system that meets the patient where they are.

Simply put, the kidney care status quo—which calls on these patients to frequently visit various clinics, hospitals and dialysis centers in person—exposes this vulnerable population to a higher risk of contracting COVID-19, and therefore serious illness or even death. Adapting quickly to the changing healthcare environment will undoubtedly save lives. But, unlike social distancing, changes to kidney care that prove beneficial to patients should be permanent. 

Establishing a comprehensive kidney care system centered on patient education, keeping patients at home and virtual care will protect those living with CKD or ESRD now and improve health outcomes, reduce costs and empower providers to deliver the best possible care in the long term.

Carmen A. Peralta, M.D., MAS, is a nephrologist, chief medical officer at Cricket Health, professor of medicine at the University of California, San Francisco and co-founder and executive director of the Kidney Health Research Collaborative.