Systematic CKD Care Approaches: A Potential Solution for the Costly ESRD Program

Abstract

Care of patients with advanced kidney disease includes dialysis, kidney transplant, vascular access, primary care, and other specialist care, which are often siloed among multiple physicians, dialysis clinics, vascular access centers, and health system or hospital-based transplant programs. Other than the patient themselves, no one provider has holistic patient visibility or responsibility. Given that hospitals often lose money on Medicare patients who require dialysis services, momentum from innovation in advanced kidney care management, new technology with the potential for reduced costs, expansion of Medicare Advantage, and Medicare incentives for home dialysis could be leveraged by health systems to ultimately reduce the nearly $50 billion annual Federal spending on patients with kidney failure in the United States. Health systems, which offer many primary and specialty care services, may be uniquely positioned to leverage the more favorable economics associated with these changes to move kidney care from siloed, provider-centric care to integrated, patient-centric care. With 60% of patients initiating dialysis through an unplanned hospitalization, a holistic health system approach that includes offerings of kidney care management and kidney replacement therapy could move financial incentives away from the interests of any single provider and toward better addressing the total needs and the goals of the patient.

Figure 1

Dialysis facilities, 1993-2019. Abbreviation: Avg, average.

Figure 2

Average Medicare spending on patients initiating dialysis, 2017-2018. Source: Health Management Associates analysis of 2017-2019 5% Medicare claims data.

Figure 3

Transplant rates after dialysis initiation, Medicare patients, 2017-2018. Source: Health Management Associates analysis of 5% Medicare limited data set.