Policy Issues in Dialysis Care

Editor’s note: This editorial was originally published in Seminars in Dialysis, as the opening letter of a special issue focused on policy issues in dialysis care. USC Schaeffer Center clinical and resident fellow Eugene Lin, PhD, was a co-guest editor for this issue and penned the below letter.

For nearly five decades, after dialysis first became widely available for the treatment of end‐stage kidney disease (ESKD), government policies have shaped nearly every aspect of dialysis care delivery in the United States. Unlike other areas of healthcare, most U.S. patients with ESKD automatically qualify for federal Medicare coverage, making the U.S. government the primary payer for ESKD care. This federal coverage mandate, combined with disproportionately high expenses of treating ESKD, long‐standing concerns about the quality of in‐center hemodialysis care, and an ever larger population with ESKD, has resulted in many new policy initiatives designed to mitigate skyrocketing costs and improve health outcomes. Bundled payments, efforts to restrain costs through administered prices, value‐based (ie, pay‐for‐performance) payment, a focus on patient‐centered outcomes, and the use of multiple methods to monitor quality, represent reform efforts that have profoundly influenced dialysis care. In many instances, ESKD‐focused policies have been at the forefront of new health policy initiatives at a national level.

The challenges that policymakers face when trying to encourage the delivery of high quality, cost‐efficient dialysis care to all patients who require dialysis are evident in the state of dialysis care today. Mortality rates among patients receiving dialysis remain extremely and unacceptably high. Patients with ESKD experience reduced quality of life, frequent hospitalizations, and are rarely able to continue working after starting dialysis. Many patients without health insurance receive substandard dialysis care through hospital emergency rooms. Meanwhile, although less than one percent of all Medicare beneficiaries have ESKD, they account for more than seven percent of overall Medicare spending.

Recognizing the magnitude and public health significance of these ongoing challenges, on July 10, 2019, the President of the United States and the Secretary of Health and Human Services announced a new wave of policy initiatives designed to improve the care of patients with advanced kidney disease. As outlined in an executive order and in the Advancing American Kidney Health Initiative, the administration set out ambitious aims to substantially reduce the number of people developing ESKD, increase the number of people with ESKD who receive dialysis at home or who have a transplant, increase the number of kidneys available for transplant, and promote innovations and new technologies aimed at treating and curing kidney diseases.

As policymakers develop and implement specific plans to achieve these goals, it is important to understand the consequences of past policies, and how past policies have brought the field of nephrology and the dialysis industry to where it is today. It is also important to understand challenges associated with current and future policy reform efforts. Only with this knowledge can policymakers, nephrology care providers, and patients with kidney disease succeed in charting a new path forward. Thus, an opportunity arose to compile a collection of scholarly reviews focusing on different aspects of dialysis care policy, from a variety of perspectives. Of note, while contributions from government officials and patients were sought out, and commissioned, these perspectives did not materialize by the deadline of this issue, which we regret. We hope that this special policy edition of Seminars in Dialysis meant to provide an overview of key past, contemporary, and future policy efforts that influence dialysis care delivery is useful to a wide readership to better appreciate the evolution and potential impact of policy initiatives on ESKD care.