The Trump administration’s latest proposal to reduce the cost of treating kidney disease by encouraging earlier, more convenient interventions and to improve the organ transplant process is extraordinary. It’s not just that the administration has proposed a reasonable policy to rein in health-care costs. And it’s not just that it’s specifically targeting powerful business interests to do so.
Rather, what’s most striking — even inspiring — is that the proposal puts much effort toward improving a single, narrow segment of health care that affects only a small portion of Americans. It’s exactly the type of policy we often need but don’t have the will to implement.
That Trump officials are pursuing this course is all the more notable because the administration’s larger-scale approach to health-care policy is so abhorrent. Trump and his fellow Republicans spent a year fumbling around with legislation to repeal the Affordable Care Act, all while demonstrating little interest in crafting a decent plan to replace it. And when it became clear that the administration wasn’t going to get the repeal done in Congress, it issued a slew of executive actions to undermine the ACA exchanges and joined a cockamamie lawsuit to see if it could trash the law altogether in court.
Those efforts have been motivated by the desire to please Trump’s conservative base, which detests the Affordable Care Act because, like the Iran deal, it is one of President Barack Obama’s key legacies. But Trump’s proposals on kidney disease don’t appear to have any such partisan aims.
Treating kidney disease is brutal. Most Americans in need of treatment do so through an uncomfortable procedure known as hemodialysis, which typically requires patients to sit for hours at a clinic multiple times a week as a machine filters toxins from their blood.
And as is so often the case in U.S. health care, patients don’t have many options about their care. Two companies — Fresenius Medical Care and DaVita — dominate the dialysis market. They run like factories, churning through patients’ blood and charging Medicare around $35 billion a year for their services. To make things worse, U.S. dialysis patients have stubbornly low survival rates compared with other countries. A 2016 study found that 39 percent of Americans on dialysis survived five years after starting treatment, compared with 41 percent in Europe and 60 percent in Japan.
Maybe it’s surprising, given Trump’s strain of populism, that we haven’t seen more proposals like this out of his administration. Trump has regularly trained his fire on powerful businesses in the health-care industry, from pharmaceutical manufacturers to the drug “middlemen” known as pharmacy benefit managers. Dialysis providers are a logical addition to that list. Indeed, their stocks plunged after news of Trump’s impending proposal broke.
The administration’s proposal would order Health and Human Services Secretary Alex Azar to test payment models that would encourage doctors to treat patients earlier, as well as encourage at-home dialysis treatment known as peritoneal dialysis, which is less expensive in the long run and more convenient for many patients. U.S. doctors often don’t take advantage of this treatment or preventative measures, however, because they have little financial incentive to do so.
Dialysis clinics are currently paid per treatment. And because of the way Medicare reimbursements are set up, the clinics pull in the most revenue by prioritizing shorter, in-center treatment, as opposed to longer, gentler treatments, so they can maximize the number of patients they treat. The centers are particularly looking to treat large numbers of patients during a phase of treatment when the centers can be paid higher rates by private insurers — before Medicare rates kick in. The administration plans to break those incentives (using a provision in the ACA, ironically) by directing the Centers for Medicare and Medicaid Services to pursue ways to reward nephrologists for directing patients away from center-based care altogether.
The administration is also proposing ways to reduce the national shortage of organ transplants, including making the organ procurement process more efficient and reducing the number of organs that are discarded. It will also instruct Azar to develop better ways to measure whether nonprofits charged with procuring those organs are meeting government performance standards — a persistent problem in some urban areas. Overall, the administration believes it can increase the number of kidneys available for transplant by 17,000 a year.
This would, undoubtedly, be a great accomplishment. Too often when we talk about health care, we focus only on the big picture issues — who’s going to pay and how should the government be involved. But we rarely go into the reasons why health care in the United States has become so expensive. Addressing the issues around kidney-disease care is a great first step to do that.
Even if you don’t care for the administration or its approach to health care, this proposal deserves your support. For too long, dialysis patients have suffered and died while waiting for the government to act. Now, they finally have a chance to get some relief.