Supreme Court’s Health Care Ruling Ushers in Host of Reforms Affecting Kidney Care

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The Supreme Court ruling upholding the constitutionality of the Affordable Care Act (ACA) gave the green light to a host of reforms that will affect the practice of kidney care.

The possibility remains that Republicans will win the presidency as well as control of both houses of Congress with majorities large enough to repeal the law or hamper its implementation. But in the absence of that large political turnabout, some changes that could affect nephrology practice include a large expansion of insurance coverage, a system needing adjustments to provide services to more people, and the output of new programs for research on care quality.

The main goal of the ACA was to increase the number of Americans covered by health insurance, and the latest projections of the nonpartisan Congressional Budget Office are that an additional 30 to 33 million people will have health insurance by 2016, an increase from today’s 82 percent to 92 percent of the population under Medicare age. One big driver of the growth in coverage is a planned expansion of Medicaid eligibility, but the portion of the court ruling that allows states to opt out of the expansion could have a big effect on these numbers (see sidebars). But in any scenario, millions more people should obtain coverage.

An underlying theme of the reform is that this increased coverage should translate into earlier and better care. “Increasing access to primary care can only be a good thing in terms of preventing and slowing the progression of kidney disease,” said Rachel Shaffer, manager of policy and government affairs at the American Society of Nephrology.

Early treatment in the primary-care environment of two common causes of kidney failure, hypertension and diabetes, could prevent or delay the need for many patients to see a nephrologist, said Thomas Hostetter, MD, chair of ASN’s public policy board: “If more people have coverage, we would not be in the position where we’ve often been, where people arrive with very advanced kidney disease having had little if any prior care.”

Another reform provision that could prove relevant is that insurers will not be able to deny coverage based on preexisting conditions, making it easier for patients with incipient or more advanced kidney disease to obtain coverage. The ACA also eliminates annual and lifetime caps on covered expenses, which could help chronic kidney disease patients who do not progress to Medicare coverage or family members on their policy.

The expansion of coverage will be driven by incentives and subsidies for buying health insurance, penalties for not buying it, and an expansion of Medicaid and the Children’s Health Insurance Program. Individuals and small employers will be provided easier access to health insurance through the establishment of health insurance exchanges set up in each state. So far, 17 states and the District of Columbia have taken the first steps toward establishing exchanges, which are scheduled to come on line in 2014. Some governors have said that their states will not participate in these exchanges, but residents of those states will have access to a multi-state exchange set up by the U.S. Department of Health and Human Services.

To be sold on the exchanges, policies will need to meet defined standards, including what the ACA calls “essential benefits packages.” The packages will be defined mostly by the states where they are offered based largely on the customary policies already available, but they will also have to meet standards for deductibles and out-of-pocket costs. The federal government will also have a role in setting standards, and one of the key questions to be answered in coming months is what essential benefits packages will include in terms of kidney care.

These issues include the availability of immunosuppressive drug coverage for kidney transplant recipients, the interface between exchange-based insurance coverage and Medicare’s end stage renal disease program, and the treatment of living organ donors, according to Dolph Chianchiano, JD, MBA, health policy adviser to the National Kidney Foundation. Chianchiano said that the U.S. Department of Health and Human Services (DHHS) is being slow to weigh in on some of these questions, perhaps to allow states the latitude to design their own programs.

Coverage of immunosuppressive drugs would obviously be critical to kidney transplant patients at the end of the three years of Medicare coverage. The National Kidney Foundation and groups like the American Medical Association have urged that the essential benefits package be modeled on Medicare Part D, which includes anti-rejection medications on its list of protected drug classes. DHHS has not yet given a specific response on whether kidney transplants and their follow-up care will have comprehensive coverage although it acknowledges that transplant benefits are typically provided in private insurance.

Another issue is whether patients who receive end stage renal disease treatment will have to enroll in Medicare, or whether they can stay on their private insurance for their care. In a Federal Register posting, DHHS said that individuals would not automatically lose their private coverage if they are eligible for Medicare coverage. In addition, new end stage renal disease patients can remain in their small group employer health insurance available through the exchanges, rather than transfer to Medicare, for the first 30 months of kidney replacement therapy, Chianchiano said.

Living kidney donors do not have a preexisting condition, “but insurance companies on occasion have acted as if they [do],” Chianchiano said. “One would assume that if you cannot discriminate against an individual because of a preexisting condition, an insurer cannot discriminate against someone because they have been a living organ donor.” This protection has not been spelled out explicitly, however.

An influx of millions of new patients will pose a challenge to a health care system already facing physician shortages, said Atul Grover, MD, PhD, chief public policy officer of the Association of American Medical Colleges (AAMC), particularly the teaching hospitals that his organization represents.

A key concern of the AAMC is whether the Medicaid expansion will take place as planned. Hospitals are facing cuts in Medicare and disproportionate share payments written into the ACA, cuts they could accept based on the assumption that with more people being covered, more patients would be able to pay for the services they receive. If some governors make good on their threats to not expand Medicaid, that will throw a monkey wrench into the whole formula. Grover looked to the experience of Massachusetts, which passed its reform aimed at universal coverage in 2006, for clues about the future.

“They had a very small percent uninsured, 2 or 3 percent, [yet] a lot of those who remained uninsured ended up in our teaching hospitals, so they had to go back and tweak the formulas for how they appropriated some of the [disproportionate share] money in those cases,” Grover said.

Looming physician shortages

The AAMC’s other big concern is that it had been projecting looming shortages of physicians and other health care professionals even before the ACA passed. “If you add to that 32 million people potentially gaining new insurance, you are really accelerating those shortages because people are going to end up in the system where maybe they weren’t going to be before,” Grover said.

Grover noted that in Massachusetts patients have not experienced difficulty obtaining care: “In primary care in particular, they have figured out how to use other health care professionals, nurse practitioners and physician’s assistants, to improve access.” But demand has risen: a study by a Boston University School of Medicine professor found that inpatient procedures increased among lower- and medium-income Hispanics and whites after the health reform law went into effect. Hispanic patients underwent 22 percent more elective surgeries, including knee and hip replacements.

Grover questioned whether a system in which Medicare has not supported its share of the cost of training physicians at teaching hospitals could adjust to more patients nationwide: “We have advocated a modest expansion of residency training to try and close a third of the gap between now and 2020 or 2025, in hopes that some of the delivery system reforms, some of the focus on prevention, can actually slow down the increase in demands for physicians’ care.”

Patient outcome research

The kidney community also has its eyes on a pair of research centers established by the ACA. The Patient-Centered Outcomes Research Institute (PCORI) is a nonprofit organization governed by a board drawn from the public and private sectors and appointed by the head of the Government Accountability Office. Created to back comparative effectiveness research, particularly kinds that are difficult to find funding for, PCORI’s research will extend to all disciplines, but could have particular benefits for nephology.

“We are the first to admit that there is insufficient hard data for lots of things that we do for patients,” Hostetter said. “There are some things that we understand well for the general population, but we get different outcomes if we use that approach with people with end stage renal disease.”

The Centers for Medicare and Medicaid Innovation is another new creation, within the Centers for Medicare and Medicaid Services, with a mission of finding new payment and delivery methods that improve care and health while lowering costs—including looking at ways to improve kidney care. As a part of this effort, DHHS has recognized 154 accountable care organizations (ACOs), groups of doctors and other providers who work together to coordinate care for Medicare recipients.

Hostetter said that ASN has weighed in with recommendations on future directions because kidney care is particularly well-suited for refinement in this sort of venue: “People with most kinds of early kidney disease can be cared for by primary-care providers, sometimes with consultation to a nephrologist. But there is a stage in chronic kidney disease where it’s important that there be integrated care, then there is a stage where it’s important that a nephrologist do essentially all of the care for the kidney portion of a person’s illness.” Research could certainly contribute to better integrating these states.

By upholding the Affordable Care Act, the Supreme Court allowed these kinds of efforts to continue. Many supporters of the ACA’s goals in the health care community acknowledged that the law has its flaws, but echoed the hope of American College of Physicians president David L. Bronson, MD, that the debate could move away from whether or not to repeal the law in order to focus on “preserving all of the good things that it does while making needed improvements.”