Oh What a Year in Nephrology

Szczech, Lynda MD, MSCE

doi: 10.1097/01.NEP.0000393754.74203.7a

Lynda Szczech, MD, MSCE, a member of the Nephrology Times Editorial Board, is Associate Professor of Medicine at Duke University Medical Center and President of the National Kidney Foundation. Her clinical and research interests include HIV nephropathy and anemia in kidney disease

Article Outline

Numerous health policy changes captured our attention and captivated our discussions in 2010. These shifts ranged from dietary modifications that may affect every single person in the United States to adjustments in reimbursement and health services delivery that may enhance or restrict care, depending on the patient population. This editorial gives an overview of some of the year's most important developments.

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Pass on the Salt

In response to mounting epidemiological data, a national effort to cut back on the amount of salt in prepackaged and restaurant foods was launched.

The National Salt Reduction Initiative (NSRI), led by the New York City Department of Health and Mental Hygiene, is a coalition of government and health organizations raising awareness about salt consumption and guiding manufacturers and restaurants to voluntarily reduce the amount of salt in their products to specific targets.1 The NSRI is modeled after a UK initiative where salt consumption dropped by 40%.

Many large companies and restaurants, such as Au Bon Pain, Boar's Head, Goya, Heinz, Kraft, Starbucks, and Subway, have committed to these targets. The National Salt Reduction Initiative aims to decrease salt consumption by 20% over five years, with the anticipated savings of thousands of lives and billions of dollars in health care expenditures.

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More Coordination

In keeping with this focus on public health and disease prevention, discussion of the patient-centered medical home has continued. The concept—introduced by the American Academy of Pediatrics as early as 1967 and subsequently shaped by various medical societies, institutions, and entities—aims to transform primary care specialties, reduce health care costs, and increase health care efficiency for patients.

Essential to the model is that each patient have a personal and ongoing relationship with a physician who is the first contact for comprehensive care. The physician should have the perspective of providing for all the patient's needs (i.e., whole person orientation) and act as team leader for the subspecialists involved, coordinating care, ensuring quality, and being appropriately recognized for these activities in reimbursement.

Medical homes are being actively promoted on the state level, and the evolution of the concept has continued with the designation of certain health information technology domains as necessary for the success of the model: telehealth, quality and efficiency measurement, care transitions, personal health records, registries, team care, and clinical decision support.2

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Health Care Reform

The theme of advances in health information technology is echoed at least in small part in the health care reform bill—the Patient Protection and Affordable Care Act—that was passed into law on March 23, 2010. The overall goal of this landmark legislation is to provide coverage to an estimated 30 million people who currently lack it. It is estimated that the law will cost the government about $938 billion dollars over 10 years.

The legislation will regulate private insurers more closely. As of September, insurers were banned from denying people coverage because of technical errors on their applications. Additionally, insurers are required to offer coverage to children under 26 on their parents’ policies. However, it is reported that waivers to maintain minimal coverage below the new law's standards are being granted.

Overall, the new law will require most Americans to have health insurance and will likely add 16 million people to Medicaid. Interestingly, though, 20 states have filed a lawsuit in federal court stating that the Commerce Clause of the Constitution does not allow the government to impose penalties on Americans for refusal to buy a product.

While the future of the health care legislation and its multitude of proposed changes is not clear, I hope its provisions on increased utilization of preventive services will contribute to the growing recognition of chronic kidney disease (CKD) at earlier stages and give patients diagnosed with the condition greater access to care.3

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Nephrology at Work

The increasing recognition of CKD is without a doubt desirable, but it brings up the issue of the number of nephrologists available to care for these patients.

While no dramatic shifts have occurred in the nephrology workforce over the last decade, the lack of such changes should be considered as big a story.

Due to a variety of issues, from recruitment to the availability of training spots, the number of internal medicine residents entering nephrology fellowships has remained stable. And although the number of nephrologists in the United States has been stagnant, the average age has not.

Unlike the nephrology workforce, the population of patients with kidney disease has continued to grow. While the incidence of end-stage renal disease (ESRD) has shown a relative stabilization, the prevalence of ESRD has been on the rise, with the 2010 Annual Data Report from the United States Renal Data System (USRDS) citing more than 500,000 prevalent ESRD patients for the year 2008.4

The number of CKD patients is climbing in a similar but perhaps more dramatic manner. This increase may be due to a number of factors, such as improved preventive care and the aging of the general population, as well as increasing recognition of the condition. The happy problem we're left with is how to adequately care for this epidemic.

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Bundling Up

Given the tremendous growth of the ESRD program, its cost to Medicare has become a priority for Congress, and the long-awaited final rule for the bundled dialysis services payment was released by the Centers for Medicare & Medicaid Services (CMS) this summer.

Starting on Jan. 1, 2011, the standardized base rate per dialysis treatment will be $229.63, with adjustments made for age, body mass index, body surface area, incident status, and certain comorbidities (pericarditis, bacterial pneumonia, acute gastrointestinal bleeding, hemolytic or sickle cell anemia, myelodysplastic syndrome, and monoclonal gammopathy).

With respect to medications, CMS will include injectable drugs and their oral equivalents in the bundle but will hold off on adding medications with only oral forms until Jan. 1, 2014. In a similar compromise from the proposed rule, the agency will allow for the separate reimbursement of non-ESRD-related laboratory tests.

The impact of the new billing system on patients will require close monitoring, many have stated.5 Attention will need to focus on intermediate outcomes and on morbidity and mortality, as the potential for both improvements and risks exists. Additionally, given the incorporation of a 20% coinsurance obligation for laboratory services—an outlay for which patients are not currently responsible—the financial implications of the bundle for patients will need to be examined.

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Onward and Upward

While the issues that we discussed in 2010 are numerous and diverse, one common theme seems to be coming to light. Whether the issue specifically relates to safety (e.g., reduction of salt in the diet) or more directly focuses on cost containment as a way to facilitate program sustainability (e.g., the new bundled payment for ESRD), the themes of patient and public safety are emerging more frequently.

This preemptive strategy to minimize the direct risks of a practice or the indirect risks of a modification recognizes that nothing about health care exists in a vacuum. Safety monitoring and a more comprehensive picture of our nation's health will be valuable as we continue these discussions into the new year.

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1. New York City Department of Health and Mental Hygiene. Cutting salt, improving health. Available at: http://www.nyc.gov/html/doh/html/cardio/cardio-salt-initiative.shtml. Accessed November 1, 2010.
2. Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood) 2010;29:614-621.
3. US Department of Health & Human Services. HealthCare.gov. Available at: http://www.healthcare.gov.
4. US Renal Data System. USRDS 2010 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2010.
5. United States Government Accountability Office. Report to Congressional Requesters. End-Stage Renal Disease: CMS Should Monitor Access to and Quality of Dialysis Care Promptly after Implementation of New Bundled Payment System. March 2010. Available at: http://www.gao.gov/new.items/d10295.pdf. Accessed November 1, 2010.
© 2010 Lippincott Williams & Wilkins, Inc.