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Trump orders overhaul of organ transplant and kidney dialysis systems

Surgeons perform a kidney transplant at MedStar Georgetown University Hospital in Washington in 2015.
Surgeons perform a kidney transplant at MedStar Georgetown University Hospital in Washington in 2015. (Linda Davidson/The Washington Post)
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The Trump administration pledged Wednesday to reduce end stage kidney disease by 25 percent by 2030, proposing to provide better care earlier in the disease’s progression and double the number of kidney transplants performed in the United States.

President Trump signed an executive order Wednesday morning that is also designed to move many of the more than 500,000 people receiving kidney dialysis away from commercial centers to less expensive in-home care.

Trump said the order delivers “ground-breaking action to millions of Americans suffering from kidney disease. It’s a big deal.”

In a briefing for reporters before Trump’s speech, Joe Grogan, head of the White House Domestic Policy Council, described the package of initiatives as the biggest improvement in kidney care since the government extended coverage of kidney failure under Medicare in 1973.

Johns Hopkins University said it has transplanted a kidney from a living, HIV-positive donor to an HIV-positive recipient. (Video: Luis Velarde/The Washington Post, Photo: Andre Chung/The Washington Post)

Medicare spends more than $110 billion on kidney care, about 20 percent of all fee-for-service dollars paid out by the giant government health insurance program.

“The focus has been on paying for procedures rather than paying for good outcomes,” Secretary of Health and Human Services Alex Azar said in the telephone briefing. “Under the president’s leadership, we’re going to flip that around.”

The initiatives Trump outlined include five new payment models to encourage doctors to treat patients earlier and encourage home peritoneal dialysis; a crackdown on some of the 58 non-profit organizations that do a poor job of collecting organs for transplant; and a public awareness campaign aimed at patients. About 40 percent of people with kidney disease do not know they have it, officials said.

Azar noted that in Hong Kong 85 percent of kidney patients who require dialysis get it at home, and in Guatemala, 56 percent use that method. In the United States, only 12 percent receive in-home dialysis, often delivered while patients sleep.

Kidney dialysis is a grueling regimen endured by about 510,000 of the 726,000 people who suffer from end-stage kidney disease, according to the National Kidney Foundation. In the United States, most people receive hemodialysis, a treatment that requires a device to filter waste and toxins from their blood. Most receive it in clinics or private facilities that serve dozens of people each day.

Average life expectancy for a person on dialysis is five to 10 years, though some live much longer.

A less expensive and less grueling option is peritoneal dialysis, a treatment that uses a fluid infused through a catheter implanted in the abdomen, often while the patient sleeps. The process is used by only a small percentage of U.S. kidney patients.

Right now, the U.S. system creates incentives for clinic-based hemodialysis. Two companies, Fresenius Medical Care and DaVita, dominate the lucrative market. Physicians generally are reimbursed at higher rates for care of dialysis patients than for treatment of patients with kidney disease who do not yet need dialysis.And Americans are not accustomed to taking care of themselves at home, something health care providers often discourage.

“Do you want to go to the clinic, where the nurses and doctors are there to take care of you? Or do you want to do it at home yourself?,” asked Vanessa Grubbs, an associate professor of nephrology at the University of California San Francisco.

Chris Meekins, a research analyst at the financial-services firm Raymond James, said a shift toward home dialysis would hit both companies but hurt DaVita more because the company has not made as large an investment in that field.

“There’s no question that the large dialysis companies have created a business model that encourages” patients to receive care at their facilities, Meekins added. More home dialysis will free patients and the people who have helped them get to dialysis centers, he said.

Meekins said he did not expect to see new rules begin to have an impact for at least a year.

In a statement, Bill Valle, chief executive of Fresenius Medical Care North America, said the company is “committed to working to achieve the broader goals of expanding access to home dialysis, transplantation and new models of value based care for chronic kidney disease.”

A spokesman for DaVita said the new initiatives would support the company’s investments to further kidney disease prevention, encourage home kidney care and improve kidney transplantation rates.

Rachel Nell Meyer, director of policy and government affairs for the American Society of Nephrology, which represents more than 12,000 kidney health care providers, said the organization was “absolutely thrilled” about Trump’s focus on kidney health and generally supports changes in payment approaches.

“Our sense is that by focusing on a more comprehensive approach to kidney health, the administration may actually improve care at every stage before kidney failure in ways the current system does not,” Meyer said.

Medicare spent about $35 billion on dialysis patients in 2016 — more than $89,000 per person, according to the kidney foundation. Transplant patients, in contrast, cost Medicare $35,000 per person.

Azar, whose father was on dialysis before he received a kidney transplant, also will be directed to develop ways to spur the development of an artificial kidney and increase transplantations of organs.

A key to boosting transplantation will be cracking down on “organ procurement organizations,” the 58 nonprofits that collect organs from deceased donors and send them to transplant centers for implantation. Each OPO holds a monopoly over a chunk of U.S. territory and collects and reports its own data on how successful it is. Some poor performers have manipulated the numbers, researchers have shown.

New York’s OPO, for example, has consistently fallen short of government performance standards but has been able to block HHS efforts to shut it down because of unreliable data.

“Clearly the current evaluation system is flawed across all aspects,” said Kevin Myer, chief executive of the OPO in Houston, where organ recovery rates have increased by more than 40 percent since he took over in 2013. “First of all, it’s self reported, which is a problem.

“I can’t think of anyone who would say our current measurement system is effective. It is not,” Myer said.

Trump will order Azar to develop better ways of measuring OPO performance that are clearer, more reliable and easier to enforce, according to people familiar with the plan. On Tuesday, Sen. Todd C. Young (R-Ind.) introduced legislation calling for similar measures.

“This is an unqualified win for patients,” Greg Segal, co-founder of Organize, a group seeking to improve organ transplantation, said in a statement. “OPO problems have been hiding in plain sight for years, but these government monopoly contractors have never received the sustained scrutiny they so desperately need.”

Trump also will instruct Azar to improve the process of matching kidney donors to recipients, as well as the speed of delivery, to reduce discards of usable organs.A Washington Post analysis of 2.7 million death records from 2016 showed that by expanding the pool of donors to older and slightly less healthy people, the transplant system could yield more than 75,000 organs for transplant annually — enough to put the nation on pace to wipe out organ waiting lists within a few years.

Another Trump proposal would increase payments to live donors of kidneys and livers to cover more of their expenses, possibly including lost wages and child care.

“Anything we can do to make living donation easier for these altruistic people should happen,” said Jason Wellen, surgical director of kidney transplants at the Washington University School of Medicine in St. Louis. “These people give of their time, stay in hospitals away from their families and give away one of their organs.”

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