In November 1971, a gentleman named Shep Glazer testified before a Congressional committee. By nearly all measures, it was a fairly standard affair. An American, acting under the belief that there was a problem that needed solving, went to Congress to state his case. His experience was nearly identical to that of tens of thousands of other Americans who have sought redress from their elected officials, save one critical difference: He did it while receiving treatment from a dialysis machine.
Today, there are half a million Americans living with kidney failure. Without a transplant, these patients cannot survive. And so, three times a week, nearly 400,000 of them undergo dialysis in their homes or in a clinic in their city, town or neighborhood. For four hours, they receive the life-sustaining therapy that is necessary to clean their blood and remove the excess fluid that, for the rest of us, our kidneys take care of.
It was not always like this, however. In the 1960s, when dialysis first became a viable therapy for people with end stage renal disease, or ESRD, the cost of the treatment was beyond the reach of average Americans. Dialysis machines existed in a select few cities, but there were not nearly enough to treat everyone whose kidneys had failed. Someone, it soon became clear, had to decide who would be lucky enough to receive this ground-breaking new treatment. Panels of experts — consisting of physicians, hospital administrators and even clergy — were convened to determine who was worthy of receiving dialysis and who was not. These were the original death panels, and they decided quite literally who would live and who would die.
Recognizing that there had to be a better way, patients, physicians and policy makers began to search for a solution. They soon found it in the new law that extended health care to our seniors. If we can pass a law that provides critical health care for our most vulnerable seniors, these people asked, why not use the same law to extend care to our most vulnerable chronic patients? And so people like Mr. Glazer came to Washington offering a path toward a better way.
Congress listened. On July 1, 1973, Medicare began to confer automatic eligibility on anyone diagnosed with ESRD. For the first time in history, whether an American was 5 or 65, the federal government would cover their cost of care if their kidneys failed.
Medicare has lived up to that commitment for the past 40 years, even as the number of people with ESRD has grown faster than anyone expected. Due to the baby boom and the increasing rates of diabetes and hypertension (two of the primary risk factors for kidney disease), there are more people diagnosed with ESRD than ever before. The kidney community — nephrologists, hospitals and approximately 5,000 outpatient dialysis centers across the nation — has done its part in creating a network of care that provides access throughout the country. The community has worked to reduce costs and improve health outcomes and quality of life for patients and their families.
In 2011, the Medicare benefit for ESRD took a major step forward and expanded what was one of the first bundled payments systems in the outpatient setting. Under this new payment system, health care providers would be paid a single rate for the dialysis treatment and nearly all of the ancillary items associated with it, including, for example, intravenous drugs and lab tests. What’s more, for the first time in Medicare’s history, reimbursement would be tied directly to quality. If a provider failed to meet certain quality thresholds, reimbursement would be reduced.
Far from resisting the change, dialysis providers embraced and even advocated for the new system. We recognized that by taking greater accountability for our patients’ care, we could improve their lives and reduce the cost burden for taxpayers. The new system was a sea change, one that we accepted with near unanimity. And by any measure, it has been a success. According to the government’s own data, patient mortality has improved, hospitalizations have declined and the cost of dialysis has been reduced. Nephrologists and dialysis providers are working together to improve patients’ lives and reduce the burden to taxpayers.
This success, however, is now in jeopardy. On July 1 — 40 years to the day that the Medicare ESRD benefit went into effect — the federal government released a proposal to dramatically cut dialysis reimbursement. Mandated by Congress to reflect providers’ efficiency in reducing the cost of care, the cut goes too far. Indeed, if the proposal is finalized, Medicare would fail to cover the basic cost of dialysis. For the first time since Shep Glazer testified before Congress while receiving dialysis treatment, the commitment made to Americans with kidney failure is in doubt.
What had been available to only a precious few prior to 1972 — a chance at life — is now available to virtually all kidney patients. What was once exceptional has now become routine. All because of the courage of patients like Mr. Glazer who challenged their lawmakers to dream of something bigger. Today, we must again look to our lawmakers in Washington and challenge them to live up to the commitment they made 40 years ago. They can make the routine even more efficient and more effective. If they fail to act, however, access to this life-saving therapy may be in jeopardy for some ESRD patients.
We can and must do better.
Ron Kuerbitz is the chairman of Kidney Care Partners, a coalition working to improve quality of care for individuals with chronic kidney disease and end stage renal disease.