Volume 19, Issue 4 pp. 995-997
PERSONAL VIEWPOINT
Free Access

Greater access to transplantation should be a priority: A view of the Dialysis PATIENTS Demonstration Act

Bryan N. Becker

Corresponding Author

Bryan N. Becker

DaVita Inc., Denver, Colorado

Correspondence

Bryan N. Becker, DaVita Inc. Denver, CO

Email: [email protected]

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Allen R. Nissenson

Allen R. Nissenson

DaVita Inc., Denver, Colorado

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First published: 24 September 2018
Citations: 1

Abstract

Fragmentation of care has been cited as a rationale toward moving to new care models with care coordination and a focus on value-based care delivery. This trend is gathering momentum in end-stage renal disease (ESRD) care given evident care gaps and the variety of healthcare entities that touch patients with ESRD in the course of their treatment. Although care models supported by chronic condition special needs plans and ESRD seamless care organizations (ESCOs) have advanced care and cost-effectiveness, their shortcomings limit their ability to support larger patient populations. New care models and potential organizational structures, such as those proposed in the Dialysis Patient Access To Integrated-care, Empowerment, Nephrologists, Treatments, and Services (PATIENTS) Demonstration Act, provide another approach toward reducing fragmentation of care, increasing patient health, and helping define better approaches to care for patients with ESRD so that they have the opportunity to be better transplant candidates. We recognize that this type of innovation represents change without certainty. We also believe that multiple levels of accountability, ongoing support for transplantation, and continued freedom of access to transplant professionals who participate in Medicare would prioritize patient health, quality of life, and choice with regard to transplantation with this care model.

Abbreviations

  • ESRD
  • end-stage renal disease
  • ESCO
  • ESRD seamless care organization
  • PATIENTS
  • Patient Access To Integrated-care, Empowerment, Nephrologists, Treatments, and Services
  • 1 INTRODUCTION

    Patients with end-stage renal disease (ESRD) endure complications from kidney failure along with multiple other chronic conditions and often face significant inconveniences in many aspects of their lives. As physicians who work for a publicly traded company that provides dialysis to these chronically ill individuals, our main objective is to find better ways to care for our patients. All of these efforts aim to keep patients as healthy as possible, with success demonstrated by patients experiencing an improved quality of life based on their own expectations. And for the majority of these patients such expectations likely include kidney transplantation.

    We know that kidney transplantation restores kidney function to a far greater extent than dialysis and is associated with improvements in health-related quality of life and reduced risk of mortality compared to dialysis.1 Indeed, kidney transplantation should be an option for as many ESRD patients as possible. Despite efforts to reduce kidney discards and use higher Kidney Donor Profile Index kidneys, there are still not enough kidneys to address the entirety of the kidney transplant waiting list today, which currently sits at 95 098 individuals. Moreover, despite regional variation, waitlist times have increased over the last decade, and living donation transplant rates have not kept up with the increase in deceased donor transplantation since 2011. We must find ways to keep patients healthier for longer periods so that they can remain eligible for transplantation. New models of integrated specialty care are, therefore, increasingly important.

    Although we and other providers participate in ESRD Chronic Special Needs Plans and the Comprehensive ESRD Care Model through ESRD Seamless Care Organizations (ESCOs), as a community, we do not yet have consensus on the best approach to integrated care for patients with ESRD. The model outlined in the Dialysis Patient Access To Integrated-Care, Empowerment, Nephrologists, Treatments, and Services (PATIENTS) Demonstration Act attempts to link positive features of the aforementioned integrated care models with added features to improve care. We and other organizations in the kidney care community believe it has the potential to deliver additional improvements in patient health and quality of life, with the outcome being that healthier patients who elect to be transplant candidates will do better as they proceed through evaluation and transplantation. Questions have been raised as to whether the model disincentivizes transplantation or whether the motives of the organizations that might participate are to avoid transplantation. We can state unequivocally no to both questions.

    2 HOW THE DEMONSTRATION WOULD WORK

    The PATIENTS Demonstration Act would establish a 5-year demonstration under the oversight of the Secretary of Health and Human Services. The Secretary would establish quality standards to assess care provided under the demonstration, incorporating the quality measures monitored in ESCOs that now include 2 waitlist measures. The Secretary would also solicit stakeholder input on those standards, and the transplant community is one of the most important stakeholders in such a process. In addition, although organizations participating in the demonstration would assume full financial accountability for patients, those organizations would not replace patients' current providers, and the demonstration would not affect a patient's freedom of choice of Medicare providers or access to Medicare benefits. In addition, the Secretary would be required to conduct a study ensuring that there are no disincentives from providing proper and appropriate care—including access to transplantation—under the program and establish processes to ensure that beneficiaries experience no disruption in access to Medicare providers or services when entering or exiting the demonstration. This includes kidney transplantation.

    3 IMPACT TO PATIENT CHOICE

    Patient choice is an essential tenet of this model. Patients can continue to see a Medicare provider of their choice, and the patient will still receive support from the integrated care team. Patients would be able to receive transplant services from providers participating in Medicare. Patients also have the choice to opt-out in this model, in contrast to ESCOs where there are no opt-out provisions.

    The demonstration would encompass patients who have ESRD already (attributed through dialysis) and, as such, does not affect pre-emptive transplantation, a treatment both gaining ground and with continued opportunities for improvement in the United States.6 The demonstration reinforces the key role of the patient's nephrologist who would continue to provide care for the patient and deliver appropriate treatment guidance, including transplant referral with support from the integrated care team. The demonstration adds additional requirements for participating organizations to provide transplantation education, counseling, and benefits for beneficiaries beyond what is provided today—an important opportunity for interactions with transplant centers in the geographic regions where this demonstration is active.

    4 ANTICIPATED OUTCOMES RELATED TO TRANSPLANTATION IN THE DEMONSTRATION

    Given all of this, we would hope that patients would be transplanted in this demonstration and at rates that exceed the transplantation rates today in the geographic areas of the demonstration. The most significant cost incurred during transplantation, the organ acquisition cost, would be excluded from a participating organization's payment, with the financial responsibility paid directly by the original Medicare program. Participating organizations also would not be responsible for providing transplantation procedures directly, but rather would pay Medicare-certified providers at fee-for-service rates to continue doing these procedures as they do today.

    Innovation, such as a new integrated specialty care model, represents change without certainty. That can be uncomfortable. The built-in checks and balances of the approach in the PATIENTS Act are designed to make certain that patients have opportunities to achieve better health, and we believe that a healthier ESRD patient is a healthier kidney transplant recipient when that event happens. At the same time, we recognize that many patients may not be eligible for a kidney transplant, and we would still like them to receive the potential benefits of integrated specialty care. One of the surest ways for us to know if integrated kidney care works is to try it with all of the appropriate scrutiny from the Secretary and from additional stakeholders who should challenge and push all of us to deliver better care for our patients. This is about doing what is right for patients. When we keep that top of mind, together we can truly improve the lives of people afflicted with kidney disease.

    DISCLOSURE

    The authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation. BNB and ARN are both employed by DaVita, Inc. and own stock in DaVita, Inc.

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