The US Senate Finance Committee in June launched an ambitious new bipartisan working group that aims to improve the care of Medicare patients with chronic diseases. Concerned that treatment of chronic illnesses—such as kidney disease, heart disease, and diabetes—constitutes 93% of the total Medicare budget, Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR) heard testimony in May from Centers for Medicare & Medicaid Services (CMS) Chief Medical Officer Patrick Conway, MD, and MedPAC Commissioner Mark E. Miller, PhD, about opportunities to reverse this trend, and followed that hearing with the announcement of the “chronic care working group.”
Chaired by Sen. Johnny Isakson (R-GA) and Sen. Mark Warner (D-VA), the working group will identify policy solutions that provide higher quality care at greater value and lower cost without adding to the deficit—and is seeking input from ASN and other stakeholders on how to achieve those goals.
People with kidney disease stand to benefit substantially from the working group’s efforts. ASN highlighted numerous opportunities to improve care and reduce cost for this population.
More than 51% of patients with end stage renal disease (ESRD) have 5 or more chronic co-morbid conditions and more than 80% have 3 or more chronic co-morbid conditions. In 2012 CMS reported on the top five most costly triads of chronic illness; chronic kidney disease (CKD) was included in four out of the five with an average cost of approximately $60,000 per capita. And although patients with ESRD make up 1% of the Medicare population they comprise over 6% of the total costs.
But policy changes related to kidney care could do more than just reduce costs. Strategies to slow the progression of kidney disease and improve transitions of care could improve quality of life for the millions of Americans with kidney disease. ASN’s complete comments are available online at https://www.asn-online.org/policy/webdocs/15.6.22asninputsfcchronicconditionswg.pdf.
Table 1 summarizes ASN’s recommendations to the working group. Chief among ASN’s input was encouragement to improve CKD care and transitions, and increase access to transplantation.
Currently, accountable care organizations (ACOs) are tailored specifically to the general population while the forthcoming (as of July 1, 2015) ESRD Seamless Care Organization (ESCO) pilot is tailored to the specific needs of patients on dialysis. No programs or pilots exist that address the needs of individuals with advanced chronic kidney disease by promoting patient-centered care, smooth transitions of care, and improved quality outcomes. ASN proposed piloting of a “comprehensive CKD care delivery model” pilot to fill a significant gap in care coordination for this chronically ill patient population—and potentially to result in savings in the Medicare program.
This pilot would be similar to but broader than the ESCO, include patients with advanced CKD, and focus on managing and slowing the progression of kidney disease and other complex chronic conditions common in patients with advanced kidney disease. Such a pilot model would build upon and borrow from many of the same concepts in the ESCO model, but expand the patient population included. Spearheading the care coordination efforts, a nephrologist would serve as the care leader for a population of patients from the time of their diagnosis of advanced CKD and would assume responsibility for their care—in partnership with other members of the care team, including dialysis providers—through the transition periods of dialysis initiation, transplantation, or end-of-life care.
Improved access to transplantation
The chronic care working group specifically solicited ideas for policies that improve care transitions, produce stronger patient outcomes, increase program efficiency, and overall reduce the growth of Medicare spending. ASN highlighted that improved access to transplantation, including pre-emptive transplantation, would directly help achieve each of these goals.
Kidney transplantation is the treatment of choice for eligible patients and compared to dialysis, markedly improves survival (Wolfe, NEJM, 1999), reduces risk of chronic medical conditions that complicate ESRD, and improves quality of life. It is also one of the most cost-effective interventions. One live kidney donation has been estimated to lead to an increase of 2 to 3.5 quality adjusted life-years for recipients and a net health care savings of $100,000 [Klarenbach et al., CMAJ=, 2006]. Yet thousands die on the wait list annually, and the number of kidney transplants remains limited by the supply of deceased donor organs—and hampered by a decreasing number of living donations.
ASN’s recommendations to the working group highlighted several policy levers that could increase access to transplantation. These included asking CMS to explore strategies to incentivize nephrologists to refer patients with advanced CKD to transplant centers for pre-emptive transplant evaluation, expanding access to pre-and posttransplant care for geographically disadvantaged kidney recipients and kidney donors through telemedicine, and eliminating barriers for potential live kidney donors
Besides these issues, ASN also urged that patients with ESRD be permitted to enroll in Medicare Advantage plans; called for expanded telehealth in the Medicare Program; and delineated opportunities to reduce medication errors.
The society will continue to collaborate with the working group and the Committee to advocate for policies that improve the lives and outcomes of people with ESRD.
