According to the Centers for Disease Control and Prevention, 37 million people in the United States are estimated to have chronic kidney disease and of this number more than 726,000 have end-stage renal disease (ESRD) requiring renal replacement therapy, a transplant, or palliative care. Of the more than 125,000 Americans who begin dialysis each year, 20% will die within a year. Managing chronic kidney disease and ESRD is a $114 billion expense, representing 23% of total Medicare fee-for-service spending.
On July 10, 2019, President Trump signed an executive order launching the Advancing American Kidney Health initiative, designed to improve the lives of Americans with kidney disease through expanding treatment options and reducing the health care costs associated with the disease. This initiative proposes revising rules to ensure donor kidneys reach patients more quickly, moving more patients from in-center to home dialysis, encouraging the development of artificial kidneys, increasing the number of kidneys available for transplant, and changing reimbursement for kidney disease treatment. As a response to the executive order, the U.S. Department of Health and Human Services (HHS) identified three goals:
1. Reduce the number of individuals developing ESRD by 25% by 2030.
2. Enable 80% of new ESRD patients in 2025 to receive either dialysis at home or a kidney transplant.
3. Double the number of kidneys available for transplant by 2030.
The initial excitement among health care providers, patient and provider groups, and industry was followed by the realization that these goals were likely to prove unattainable in the time frames defined. There are insufficient kidneys available for transplant, a shortage of nephrology nurses and nephrologists, a nephrology nurse and nephrologist workforce that will require time and education to prepare for a shift to home dialysis therapies, and a need to prepare additional providers to offer preventive education and care to patients in early stages of kidney disease. Additionally, technologies will need to be developed to meet these goals.
Following the definition of goals by HHS, the Centers for Medicare and Medicaid Services published and invited comments on the Specialty Care Models to Improve Quality of Care and Reduce Expenditures, a rule proposing implementation of two mandatory Medicare payment models-the End-Stage Renal Disease Treatment Choices model and the Radiation Oncology model-both of which strive to reduce Medicare spending while preserving or enhancing quality of care. Historically, when new payment structures affect the financial bottom line of kidney care providers, nurse staffing ratios are reduced. This remains a future concern for nephrology nursing because of the ripple effect these changes may have on nephrology practice settings already experiencing a nursing shortage.
I was recently in Washington, DC, discussing this initiative with nursing and kidney community leaders, in particular focusing on the possibility that the proposed payment model for patients with ESRD or requiring radiation oncology may be applied to patients with other chronic conditions in the future. Such changes that impact payment models, treatment modalities, nursing care delivery models, and practice settings have broad-reaching implications for nursing, particularly in relation to shortages experienced by many nursing specialties.
These potential and actual policy changes require nurses to become involved and engaged. Nurses must be involved in the discussion, planning, and implementation process at the legislative and practice levels and collaborate with colleagues and patients to address the implications for all parties involved. We must also design innovative nursing care delivery models that allow RNs and advanced practice nurses to practice at the top of their licenses. While nephrology nursing may be charged with leading this effort, this is an issue for the community of nursing at large.