Last week a long, heated, and expensive campaign concluded when California’s Proposition 8 capping dialysis payments failed.
This debate shattered the state’s spending records for a ballot measure, and, while some of the state’s recent ballot measures have drawn more national attention, it’s not surprising that so much was spent as so much was at stake.
Dialysis is a big business, and it comes with a big price tag. While Medicare covers the vast majority of dialysis patients, commercial payers can pay well north of $100,000 a year per patient on dialysis care. Between Medicare and private payers, we spend more than $100 billion per year treating persons with kidney disease.
So Proposition 8, which sought to cap the amount dialysis providers could charge, had some pretty huge implications. For dialysis companies, it represented an existential threat to their financial model, while payers saw an opportunity to finally see some rate relief.
But this debate of Prop 8 missed the larger point. Simply capping dialysis rates actually does nothing to change a care model that is fundamentally failing kidney disease patients, resulting in worse care that unnecessarily disrupts and shortens lives. Yes, dialysis costs commercial payers too much. However, to truly change the overall cost of care for this vulnerable population, we need to totally transform how we approach kidney care in this country so that we keep patients healthy, at home, and out of the hospital.
Kidney disease is one of those little-discussed, but costly chronic conditions that takes a huge toll on those who suffer with it — and those who pay for their care. The scale of the problem is massive. Kidney disease affects one in seven adults in the U.S. — about 30 million persons — and is the ninth leading cause of death.
But unlike almost every other chronic condition, there are no incentives for prevention and early detection of kidney disease. Rather, the incentives and reimbursement structure push people with chronic kidney disease into in-center dialysis — 88 percent end up there.
If we reimbursed for heart disease like we do for kidney disease, we wouldn't pay for cardiovascular prevention, statins, or aspirin, but we would wait and pay for a heart-lung machine.
Today, most patients don’t even know there are other choices beyond in-center dialysis. Even worse, many don’t know they have kidney disease — nine out of ten people who have stage 3 chronic kidney disease don’t know it.
In this moment with so much attention on kidney care, we have a real opportunity to fix the broken kidney care system.
To do that, first payers and health systems need to leverage health data to identify high-risk patients well before kidney failure and focus on slowing the progression of the disease. Second, we need to better educate patients about their options, including transplants and conservative management, to help them make informed decisions about their care.
Finally, if patients do need dialysis, we need to do more to to ensure that the experience is not overwhelming and demoralizing. That means increasing the use of in-home dialysis and creating an in-center dialysis experience that helps empower patients to be in charge of their health and in control of their life.
The good news is that this debate has shed light on our broken kidney care system, and we hope it jump starts a larger conversation about how to reshape kidney care. At Cricket Health, we have already seen some attitudes changing as we have conversations with payers. When we started the company, payers were very focused on the cost burden of dialysis care. Now they are increasingly focused on the best ways to get ahead of the disease.
While Prop 8 failed, we hope to see new approaches to reshaping kidney care across the country over the next several years that eliminate the burden of kidney disease for patients, providers, and payers.
Carmen A. Peralta is a renowned nephrologist. She currently serves as Chief Medical Officer at Cricket Health, a specialty care provider of integrated nephrology and dialysis care for people with chronic kidney disease (CKD) and end-stage renal disease (ESRD), and is a Professor of Medicine at the University of California, San Francisco.