Kidney Week Session Highlights Health Care Allocation

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The 40th Anniversary of Medicare’s ESRD program served as the backdrop at Kidney Week’s public policy session on health care allocation, featuring the Christopher R. Blagg Endowed Lecture in Renal Disease and Public Policy. Although the passage of the Medicare ESRD program in 1972 resolved the basic need for life-saving dialysis therapies, issues about appropriate allocation remain.

This year’s endowed lecturer was Bruce Vladeck, PhD, a former administrator at the Health Care Financing Administration, currently serving as an adviser at Nexera, Inc. The major allocation issues in the care of dialysis patients today are poor management of those with the highest needs, conflicts between clinical care and financial incentives, and increasing expenditures for terminally ill patients, Vladek said. Although the work done at the institutional level by Blagg and his colleagues was invaluable in shaping the policies of the 1960s and 1970s, Vladeck called on clinicians to come back into the fold and to be the drivers of making policy and guidelines.

Although we live in a country that refuses to ration care on principle, it is often rationed implicitly, Vladek said, usually by socioeconomic status. Using data from the United States Renal Data System to back up his argument, Vladek said less than 50 percent of total Medicare expenditures for ESRD are actually spent on dialysis services, and the dialysis population is rife with comorbidities requiring other services and hospitalizations. He stressed that comprehensive primary and coordinated care could help reduce costs, but such care is not available to the sickest and poorest patients, who need it most.

The comprehensive care model envisioned by Vladeck would also include frank and open discussion about end-of-life care, another issue that has been part of heated debates on rationing care. Public and political discourse on providing palliative or hospice care in the place of life-sustaining procedures has often turned into talk of “death panels.” But with an increasing numbers of frail and elderly individuals starting dialysis, Vladeck said the real issue is lack of appropriate training for health care providers to discuss issues related to prognosis, death, and expectations for treatment for patients nearing the end of life.

Creating policies that better address palliative care was discussed by Manjula Kurella Tamura, MD, associate professor of nephrology at Stanford University School of Medicine. Palliative care, defined as care that relieves symptoms without a curative effect on an underlying disease or cause, is unlike hospice care in that it can be used during the entire course of the disease, not just in the last 6 months. Tamura described research showing that although palliative and hospice care is not cheap, it is not necessarily more expensive than regular care. Research has also shown that palliative care has been associated with increased patient and family satisfaction and improved bereavement outcomes; it has also been shown to lower costs, primarily by reducing the number of visits to the intensive care unit.

Unfortunately, ESRD patients typically receive only 3–4 days of palliative care on average, and confusion about how Medicare and hospice care work together for dialysis patients remains an issue (hospice care is not covered for dialysis patients unless their primary need for hospice is due to a different disease). There is also a scarcity of providers trained in palliative care and a need for rigorous trials to measure the effects of palliative care, especially for the dialysis population.

Tamura laid out five ways practitioners and other stakeholders can use policies to promote palliative care for this population: 1) universal screening for palliative care during transitions to care; 2) incorporating palliative care as a process measure in Medicare’s quality improvement program; 3) payment reforms, including concurrent care models and adding palliative care as an accountable care organization designation; 4) palliative care training for ESRD providers; and 5) increased funding for research into palliative care.

Like dialysis, allocation issues also abound for transplant patients. Milagros Samaniego-Picota, MD, associate professor at the University of Michigan, tried to present balanced arguments both for and against the use of financial incentives to increase donation. In the United States, the demand for organs continues to far outweigh the supply, with only a nominal increase in the number of donors in the past few years. Many states have implemented programs to help living donors through tax credits or deductions, and a national donor assistance program now exists, but direct reimbursement for the donation of organs remains illegal under the National Organ Transplant Act.

In her “for” argument, Samaniego-Picota cited an economic model used to estimate the benefits of providing reimbursement to living donors. The authors of the paper argued that the effects of reimbursement (increase in the donor pool) would outweigh the costs (possible abuse and corruption), but they included the caveat that donors should be paid upwards of $100,000 and that compensation should be included as part of the medical procedure. They suggested that signing up for living organ donation is much like joining the military and that compensation for donation is similar to a family member receiving life insurance.

To argue against compensation, Samaniego-Picota described regulated incentive programs already in place in several countries, including Iran, Israel, Pakistan, and the Philippines. Although many of these programs have shown a demonstrable increase in kidney donations, ethical and legal concerns remain. For example, although Iran’s kidney transplant wait list has been virtually eliminated, most organs come from an impoverished population more vulnerable to exploitation. In the Philippines, rules regulating the percentage of foreign recipients have been ignored, causing rampant transplant tourism. Clinical guidelines for donors in other countries are not as stringent as those in the United States, possibly leading to an increase in adverse outcomes for this already vulnerable population.

How best to use and protect living kidney donors remains a complex problem, and Samaniego-Picota’s arguments highlighted many ongoing issues in incentivizing donation.