At the recent signing of the Trump administration’s kidney care executive order, the excitement in the room was palpable. For me, the patients on stage defined the moment as they described their personal experiences after receiving their kidney disease diagnosis, feeling alone or like providers have failed them.
These stories are all too common among patients living with chronic kidney disease (CKD) or end-stage renal disease (ESRD). Today, 90% of patients with early stages of CKD are not aware they have it, and over half of those who have progressed to severe loss of kidney function still remain unaware. The result is too many patients spending years on life-altering in-center dialysis and a $114 billion bill for CKD and ESRD patients for Medicare each year.
Systemic failures allow CKD to progress to a near-critical stage without intervention, and it leaves providers with few resources for prevention. It’s clear our kidney care system needs to change. Now, the question is: Can the administration’s kidney care initiative help?
The goals the executive order sets out are lofty and ambitious. They won’t be achieved overnight, and progress requires the cooperation of the entirety of the kidney care community. True transformation can only come only when we are also willing to address social and behavioral determinants of health. That said, these goals are focused on the right directional changes needed to rebuild our kidney care system and improve the health of millions of patients living with CKD and ESRD.
The first goals the executive order sets are 80% of new ESRD patients to either receive a kidney transplant or hemodialysis at home by 2025 and doubling the number of kidneys available for transplant by 2030. While many patients safely receive dialysis at home in other nations, 88% of patients with ESRD in the U.S. end up on in-center dialysis. This means leaving their jobs, families and homes for hourslong visits multiple times per week.
Ultimately, making home dialysis more widely available or eliminating much of the need for dialysis through transplants will enormously improve quality of life for patients with ESRD and lead to more positive health outcomes. But shouldn’t we focus on preventing kidney failure from happening in the first place?
Lowering the number of patients who develop ESRD by slowing CKD progression in earlier stages is a critical step in transforming our kidney care system. That is something the new initiative got right by including a goal to cut the number of Americans developing ESRD by 25% by 2030.
Progress toward this goal would improve lives while decreasing costs associated with kidney care, but the only way to achieve it will be through much earlier identification of CKD and effective disease management. This requires increased screening for members of high-risk populations, educating them about easily identifiable risk factors, engaging primary care providers and guiding patients through their care choices.
For far too long, the most profitable thing in kidney care has been to place a patient on in-center dialysis. Until this changes, we cannot effectively transform kidney care. The Centers for Medicare & Medicaid Services (CMS) recognized this and recently proposed new payment models for both CKD and ESRD care. Department of Health and Human Services Secretary Alex Azar described this problem best when he said, “Decades of paying for sickness and procedures in kidney care, rather than paying for health and outcomes, has produced less-than-satisfactory outcomes at tremendous cost.”
While the devil is in the details, it is encouraging to see CMS attempt to shift payment to earlier stages of CKD and alternatives to in-center dialysis. For this all to work to lower costs and provide better care, we need coordinated care outside nephrology and dialysis managing patients’ total health.
We hope this change in Medicare reimbursement will catalyze broader change, as commercial payers follow suit. While our kidney care system is flawed, it’s not beyond repair. What we have now is an opportunity to fix it.
Carmen A. Peralta, M.D., MAS, is chief medical officer of Cricket Health.