The Changing Landscape of Nephrology: Will you Lead or Follow?

It is said that the only constant in life is change. Throughout my career, health care policy changes have often been seen as harbingers of more difficult times for physicians in American medicine. Many of these changes, such as Medicare and Medicaid reform, the Health Maintenance Organization experience of the 1980s and 1990s, the consolidation of health insurance companies, and the enactment of the Affordable Care Act, had major impacts on the provision of health care. However, on balance, these changes have had positive effects, including allowing more patients access to see their physicians and to participate in preventive care programs, and for health care to start down the road of true reform. No doubt the changes required greater documentation, utilization of more restricted formularies, and ushered in the age of greater physician oversight, a pattern that continues today.

Presently, physicians in general and nephrologists in particular are under increasing pressure to conform their practice to administrative rules. Utilizing electronic medical records, constantly being subjected to measures of patient satisfaction, and most notably, entering an era where compensation is based on quality of care delivered rather than simple fee-for-service have greatly added to nephrologists’ workload and anxiety.

The present day triple aim of providing patient-centered care that satisfies the patient, while delivering high-quality care and attending to cost-saving measures is highly desirable. However, how present day care delivery systems are to adapt to fulfill any or all of these aims effectively is yet to be determined. Without fail, the nephrologists with whom I meet speak of having to do more with less, and having to spend more time and energy to get anything accomplished. They are challenged with increased documentation rules, more barriers to providing patients with their medications, more metrics addressing their practice, and ever more limited resources to support their mission in terms of support staff in the practice and at dialysis units and, most notably, in trying to coordinate care with patients’ insurance providers.

How do we, as nephrologists, ensure that our patients can continue to receive high quality care, that further increases in required reporting accomplish the goal of adding to and not detracting from patient care, and that we can find satisfaction in our chosen profession? Clearly, there are no simple answers. However, we must start by firmly advocating for our patients and our profession. Through the American Society of Nephrology and other professional organizations, there are opportunities to work as a community, together with our colleagues and our patients, and to try to have important conversations about the future. As providers of care, we are best suited to assess the present environment and see what works and what does not and cannot work in achieving not only the triple aim, but a quadruple aim that also accounts for physician satisfaction, so essential in assuring that devoted practitioners continue to provide care in the most productive, effective manner.

As the alphabet soup of EMRs, MACRA, ESCOs, and ACOs become more a fabric of our professional life dominating CKD, ESRD, AKI, RPGN, and our other more familiar acronyms, we must work together and be the leaders for designing and managing our practices (let alone research and teaching opportunities), utilizing all of our expertise and directly shaping the future.

We must get started. It will definitely be challenging, but there is much to be gained with activism and participation, or much to be lost if we fail to be involved.

January 2018 (Vol. 10, Number 1)