State of Kidney Care 2017 American Society of Nephrology

The more things stay the same, the more things change—or, at least, the more things need to change. That may be turning an old adage on its head, but turning things upside down seems to capture events since the last report on the state of kidney care in 2016.

For things to stay the same is not an acceptable state in nephrology, considering there are an estimated 40 million Americans living with kidney diseases and for nearly 700,000 of those individuals access to dialysis or a kidney transplant is their only chance to live. With a life expectancy of 5 to 10 years on dialysis, our patients with kidney failure must constantly confront the national organ shortage crisis: every 14 minutes a patient is added to the kidney wait list and every day, 13 patients die waiting for a kidney transplant.

These numbers are unacceptable, and we must be willing to say so.

As a chair of medicine at Mt. Sinai, member of the American Society of Nephrology (ASN) Council, and a transplant nephrologist/immunologist, I can say clearly and unequivocally, we need to “get real” when talking about kidney diseases; the devastating toll on patients, their families, and caregivers in the United States and across the globe; and the challenges we face confronting this epidemic.

Where there is change, some is good and some is less so. ASN supports the move away from a volume-based to a quality-based payment system in the new Quality Payment Program (QPP). The growth of alternative payment models (APMs) and the testing of physician-focused payment models under the QPP may well provide innovative approaches to care and less strenuous reporting requirements for clinicians.

However, the QPP is still a new, evolving program that has a way to go to address the needs of nephrologists reporting in the Merit-based Incentive Payment System (MIPS) as there are few nephrology-specific quality measures in the quality category and literally no nephrology-specific measures in the cost category—two of the four reporting categories that determine whether clinicians will see a bonus or a pay cut.

In the last year, Congress has considered significant changes to health care in the name of “repeal and replace” of the Affordable Care Act, generally without much debate or input from stakeholder groups. This changing environment has left health care professionals, insurers, and patients concerned and weary. ASN has worked with peer societies to preserve important policies, with varying results: access to Medicaid remains in place and patients cannot be denied insurance coverage for “pre-existing conditions” like kidney disease or having donated a kidney—but improvements to the existing law are clearly needed.

Moreover, the big picture changes needed in nephrology are going to require us to be the agents of change. It is time for us to decide whether we are up to the challenge so eloquently expressed by James Baldwin: “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

As the chief medical officers (CMOs) observe, the challenges ahead are multitudinous—touching on a transforming health care system and the role of the nephrologists in that system, the role of both government regulators and health information technology, and the need for innovation in kidney care therapies and kidney care delivery models. ASN and the CMOs also see similar opportunities in this evolving environment. A great deal of opportunity exists to improve care for patients across the kidney care spectrum: kidney diseases, acute kidney injury (AKI), kidney failure, transplantation, and end-of-life care.

And while we need innovation in both therapies and care delivery, too often it is easier to use the lack of innovation in kidney care as an excuse. We need to get patients into our care earlier, identify reversible conditions early, and more aggressively manage their conditions, while simultaneously working to identify new therapies.

ASN is also wrestling with how best to articulate the role of nephrology and the nephrologists during this transformative period. Since kidney patients often present multiple comorbidities and their care cross-cuts multiple medical disciplines, it is sometimes challenging to clearly articulate what a commonly agreed upon role for nephrology and its clinicians should be. In an era of evolving care models, ASN agrees with the CMOs that it is very important that nephrologists find their voice and express their role and value. This demonstration is critical to demonstrating the value of including nephrologists in care models.

Innovation must occur if we are to impact the current epidemic, that much is very clear. We cannot rationalize the value of nephrology as an essential part of the care plan for kidney diseases if the status quo is maintained. The lack of new therapeutic approaches will lead to the stagnation of the specialty and continued decline in interest from fellow candidates.

Recognizing the relative lack of innovation and new therapies in nephrology compared to other medical subspecialties, ASN launched the ASN Innovation and Discovery Task Force this summer. This task force is instrumental to achieving the second goal of the ASN Strategic Plan: “Transform kidney research through discovery and innovation to prevent, treat, and cure kidney diseases.”

The task force has reviewed ASN’s portfolio of current activities as well as external initiatives such as accelerator concepts that offer financial and other incentives to identify, select, and accelerate a portfolio of solutions. The task force also has examined venture philanthropy, which takes concepts and techniques from venture capital finance and business management and applies them to early stage funding for biotechnology and pharmaceutical companies to develop breakthrough drugs. These and other programs conducted by peer medical societies, patient organizations, foundations, and other innovators are among those the task force is reviewing.

With innovations in kidney therapies, there also comes a need for innovation in care delivery—including preemptive transplantation, increased access to home dialysis and telemedicine, and comprehensive care models. In care delivery, as clinicians, we know how dangerous transitions can be, whether from the hospital to the dialysis unit, or onto dialysis in the first place, or from dialysis to treat AKI onto maintenance dialysis for kidney failure, to name just a few.

The ASN leadership and I believe that a comprehensive kidney care delivery model could be much broader than an ESRD Seamless Care Organization (ESCO)—encompassing patients with advanced kidney diseases and including kidney transplant recipients, coordinating their transitions as their conditions progress, and managing and slowing progression of kidney diseases and other complex chronic conditions that are common in the kidney patient population.

Reflecting the fact that transplantation is, for many patients, the optimal therapy for kidney failure, such a care delivery model would include transplant recipients for the duration of their lives, providing continuity of care and aligning incentives. A comprehensive kidney care delivery model would present a unique opportunity to provide better, more cost-effective, and more patient-centered care than is possible under the current delivery system.

ASN and nephrologists must better quantify their value and health care system savings. In a value-based system, not being able to quantify your value is a losing proposition. With Medicare spending $103 billion annually on kidney patient care (including $32.8 billion on care for beneficiaries with ESRD), those striking statistics might appear to be sufficient quantification, but looking at society’s complacency with the current environment suggests it is not.

Instead, the kidney community and nephrologists must begin to demonstrate that coordinated, team-based care that actively involves the nephrologist in the management of patients with kidney disease is an opportunity for cost savings within health care systems. We know firsthand that these patients represent some of the highest utilizers of resources in at-risk care models, and it will take our involvement and commitment to address ways to reduce those demands while providing our patients with the best care possible.

There are multiple areas of potential collaboration for CMOs and ASN from working on creative care models to advancing opportunities for innovation, all with the nephrologist voice and what’s best for patients front and center. ASN welcomes the opportunity to work with CMOs and other kidney community members. There is much work to be done and more hands, hearts, and heads are welcome.

October/November 2017 (Vol. 9, Number 10 & 11)