Currently, the US spends $ 410 billion annually on untreated kidney disease. According to the Centers for Disease Control and Prevention (CDC), 90% of people with chronic kidney disease (CKD) don’t know they have it. Even more worrying is how CKD disproportionately affects people of color.
Health equity is an important issue for people in the later stages of kidney disease, including end-stage kidney disease (ESRD). While ESRD can affect anyone, it is more common in marginalized communities. Black / African Americans are almost four times more likely to develop kidney failure than white Americans. Latinos are 1.3 times more likely to have kidney failure.
Underserved populations are also less likely to receive quality care for their disease. With limited access to optimal treatments, they experience higher hospital readmission rates ¾ and the Covid-19 pandemic has exacerbated these inequalities.
According to the Centers for Medicare & Medicaid Services (CMS):
- While Black / African-Americans make up 7.5% of all Medicare beneficiaries aged 65 and over, they make up 33% of Medicare beneficiaries with CKD, followed by Native American / Alaskan (30%), Hispanic (28%), and Asian / Pacific population Islanders (26%). White (23%) benefit recipients had the lowest percentage of CKD.
- Outpatient hospital spending that included dialysis treatments was highest in underserved patients with ESRD.
- Average Medicare outpatient hospital spending was 5-12% higher for 65-year-olds and different populations with ESRD compared to white ESRD patients of the same age.
- The 30-day readmission rate for 65-and-older Black / African Americans with ESRD is 19% higher than the readmission rate for similarly aged non-Hispanic White Americans with ESRD.
Rising obesity and diabetes rates also increase the prevalence of kidney disease, and statistics show that minorities and low-income populations have a disproportionate risk for this chronic condition. In his blog, Dr. Bruce Quinn: “Social determinants of health impacts not only for those who end up with ESRD, but also the quality of health care they can access. Closing these gaps in health equity would help combat this devastating disease, provide better access to health care, and reduce costs for the US health care system. “
These differences are related to the patient-related, clinical, and systemic factors that need to be addressed in our control. Thankfully, CMS is finally bringing health equity to the equation with its proposed changes to close the racial differences ¾ and the time has come.
Health equity changes proposed by CMS
CMS recently proposed substantial and timely changes to reimbursement to address the racial discrepancy surrounding the mandatory kidney disease payment model. The rule proposes changes to the ESRD Treatment Choices (ETC) model to encourage healthcare providers to balance home dialysis and kidney transplant rates in ESRD patients with lower socioeconomic status with those of other health equity.
These revisions are in line with President Biden’s Executive Order 13985 to Promote Racial Justice and Support Underserved Communities through the Use of Technology and Feedback to Evaluate Data and Implement Systems That Include Race, Ethnicity, Medicare / Medicaid Dual Privilege Status, Disability Status, LGBTQ + and socio-economically consider status. Also included are new methodological approaches to promoting equity through the ESRD Quality Incentive Program.
Promoting racial justice and helping underserved communities are of paramount importance. The proposed changes could address the health and socio-economic disparities that account for more than 33% of CKD and ESRD cases.
Diverse approach to resolving disparities
The proposed CMS changes include a two-step approach that would benefit both providers and people with late-stage kidney disease. First, there is an additional health equity incentive to improve scoring. Under the current ETC model, participating providers are rewarded for increasing the patient population receiving home dialysis or transplantation. The proposed changes would add a scoring incentive to care for double-entitled patients or Medicare patients receiving a low-income subsidy. Providers who have shown positive results in treating low-income patients, either on home dialysis or transplant, could earn additional points.
The second part of the two-step approach stratifies performance benchmarks based on patient composition and evaluates the provider’s performance against benchmarks set by comparable nephrology practices that are not included in the ETC model for home and in-center dialysis claims. More underrepresented individuals will have improved access to alternative kidney replacement treatments, including home dialysis, which often leads to better health outcomes, greater patient autonomy, and improved quality of life.
Customized benchmarking based on the patient population helps participants focus more on care and less on potential financial penalties, resulting in better outcomes and a better quality of life for the individual.
These incentives encourage participating institutions and senior clinicians to improve their patients’ health equity. Most importantly, the changes encourage providers to help ESRD patients with a lower socioeconomic status access alternatives to in-center dialysis, particularly home dialysis and transplantation.
Health differences are not new. Commercial insurers typically follow the example of CMS, which will build on this dynamic. While these changes require the necessary steps, more needs to be done – both in relation to kidney care and beyond. Health organizations can now use multiple approaches to deliver health equity, including home care, which addresses social determinants of health and encourages facilities to treat low-income patients.
In addition to the flexibility home care can provide when it is available, artificial intelligence (AI) algorithms can identify patients earlier, including some people who may fail completely, providing the opportunity for programs and early interventions that can May delay the need for treatment. This comprehensive view of the patient is particularly helpful for people without a permanent address or family doctor. Data collected from a wide range of providers can be fed into the algorithm and identify patients earlier, which provides a more complete picture.When developing AI algorithms, care must be taken that no distortions are introduced. Used correctly, these tools have the ability to identify and even reduce disparities.
As with all the first steps, there are more to come. Kidney disease is experiencing a wave of innovation that is expected to bring new standards that can be applied to other chronic diseases in the future while making care more equitable.