The White House is expected to release a new executive order on chronic kidney disease treatment priorities, rules and payment experiments this afternoon. This is outside of my area of expertise, but so far, the pre-reporting indicates that this looks to be both a big deal and good news.
I will let Dylan Matthews at Vox explain more:
The order has three major parts: one on living kidney donors, one on deceased donors, and one on alternatives to center-based dialysis.
The executive order attempts to reform the system for living kidney donors (like me), as well as living liver, lung, and intestine donors, by making sure donors are held financially harmless for donating…
The second aspect of the executive order targets deceased donation. In the US, there are 58 agencies with local monopolies over the provision of dead people’s organs, known as organ procurement organizations (OPOs). For some time now, independent analysts and investigative reporters have argued that OPOs are underusing deceased donor organs by the tens of thousands….
executive order scraps the existing evaluation system in favor of two simple, harder-to-game criteria….
the Affordable Care Act, in one of its lesser-known, cost-focused provisions, set up the Center for Medicare and Medicaid Innovation, which has the authority to pursue cost-saving treatments that improve quality of care. The executive order instructs the centers to experiment with new approaches to provider payment — like rewarding nephrologists for directing their patients toward transplants, and for preventing patients from progressing to kidney failure for as long as possible
Transplants are the big deal conditional on individuals advancing to end stage renal disease(ESRD). Transplants in the out years are cheaper than end stage renal disease dialysis while managing the chronic kidney disease (CKD) progression is far cheaper than end stage and transplants as shown in the 2020 ACA Adult Silver risk adjustment co-efficiencts for HCC 183, 184, 187, 188.
|HCC||Disease||Silver 2020 Adult Co-efficient|
|HCC 187||CKD Stage 4||0.985|
|HCC 188||CKD Stage 5||0.985|
|HCC 183||Kidney Transplant Status||6.035|
Beyond the simple fact that a transplant in the out-years is cheaper, it often is a much higher quality and quantity of life than ESRD with dialysis. People with successful transplants aren’t tied to an exhausting local dialysis center with limited opportunities for travel or work.
The ideal payment models should be set up to make managing CKD at lower levels of severity to be more profitable for risk bearing entities than moving these individuals to first transplant and then long term center-based dialysis. Ideally, dialysis centers are merely a short term bridge to a transplant instead of a common long term quasi-solution.
The Center for Medicare and Medicaid Innovation (CMMI) is one of the core elements of this executive order. CMMI can come up with payment models that bypass Congress to see if a new way of paying for care improves quality and/or lowers cost for a constant level of quality. If the model shows actuarially sound value improvements in pilot projects, then CMMI can take the model national. The kicker is that CMMI is a creature of the ACA which seems to be under threat in the courts again. Without the ACA, the entire payment reform part of the executive order falls apart.