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A smarter path to prevent and treat kidney disease in the U.S. 

Three days a week, Bernard Trujillo, 60, has

Three days a week, Bernard Trujillo, 60, has 4-hour sessions at DaVita Lakewood Dialysis Center in Colorado. DaVita is one of two major companies lobbying to have Medicare favor treatment at their facilities, not in private homes Credit: Denver Post via Getty Images/Joe Amon

More than 37 million Americans suffer from kidney disease. It is the nation’s ninth-leading cause of death, and the most common treatment for the disease is so onerously expensive that kidney failure is one of only two conditions that qualifies sufferers for Medicare coverage automatically and immediately upon diagnosis (the other is ALS, also known as Lou Gehrig’s disease). Medicare spends $114 billion a year, about 20 percent of its entire budget, on kidney disease treatment. And as impactful as kidney disease is, the United States does a woefully inadequate job of preventing, diagnosing, treating and curing this disease.

But things are looking up.

Last month President Donald Trump issued an executive order aimed at overhauling the way the nation approaches kidney disease, introducing a new approach that medical experts say promotes progress on three key issues related to kidney disease:

  • Reducing the number of Americans with end-stage renal failure by increasing preventive care and early diagnosis.
  • Increasing the use by patients in end-stage kidney failure of home dialysis and increasing access to kidney transplants. The United States hosts an enormous and influential for-profit network of about 6,300 brick-and-mortar dialysis clinics, and that’s how most people in kidney failure get treatment. But studies show that the nightly at-home dialysis that patients can undergo while sleeping is both healthier and less expensive than the three-times-a-week, four-hour-long clinic visits that have been the norm for decades, and that kidney transplants are a healthier and more permanent solution than traditional dialysis, too. Only about 12 percent of Americans in kidney failure currently receive dialysis at home, and just 3 percent receive a kidney transplant each year. Trump’s initiative aims to move 80 percent of sufferers to one of these treatments.
  • Increasing organs available for transplant by encouraging more people to choose to be living organ donors or commit to having their organs donated upon their deaths, modernizing and streamlining the donor system, and incentivizing the invention and manufacture of artificial and wearable kidneys.

The biggest changes mandated by Trump’s order have to do with the way Medicare incentivizes and pays for the prevention and treatment of kidney disease. It pushes screening, early intervention, home dialysis and transplants and ends the system’s preferential payment treatment of in-house care at dialysis clinics.

Two enormous companies, DaVita and Fresenius, dominate the dialysis business, with a combined 5,100 clinics and $24 billion in annual revenues, and they’ve lobbied and contributed heavily to keep the Medicare payment structure for kidney disease treatment unchanged in its favoritism toward treatment on site in their facilities. It’s well past time for a shift, and now industry innovators are cropping up to provide cheaper and better options.

Much of the prevention will focus on increased screening for and treatment of diabetes and high blood pressure, two leading causes of kidney disease that are on the rise in the United States. But more and earlier screening for kidney disease itself will be a focus, too, because today 40 percent of people with kidney disease do not know they suffer from that ailment until their organs begin to fail.

Now Congress has a part to play, as does Gov. Andrew M. Cuomo, and the people of New York and the nation. A bipartisan bill introduced this year in both the House and Senate would prohibit life, disability, health and long-term care insurance companies from denying or limiting coverage or charging higher premiums of living organ donors, a huge step. It would also amend the Family and Medical Leave Act to make organ donation a covered condition, and direct the Department of Health and Human Services to promote organ donation through education and outreach.

And a bill passed by both the State Assembly and the Senate and waiting for Cuomo’s signature would greatly improve organ donation in New York. The bill would update state regulations to meet current standards of the Uniform Anatomical Gift Act, as 47 other states already have, a crucial step in participating in organ donations that cross state lines. It would clear up the process by which people can opt to make anatomical gifts upon their death. It also would amend the law so that it’s harder for one relative to stop a donation when the majority of family members who are equally closely related to the donor support donation.

Advocates say these state changes could mean another 600 organs available for life-saving donations in New York annually. That’s a huge deal in a state ranked 50th in the nation in organ donation, where 92 percent of residents say they support the practice but only 27 percent are registered as donors. About 400 people died in New York last year for want of kidneys alone, and that’s more than were killed by drunken driving. Better prevention, education, screening, treatment, laws and encouragement of organ donation could cut that fatality number way down. And Trump’s executive order, along with action from Congress and Cuomo, can make that happen.


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