Azar: kidney dialysis needs to move to patient homes

HHS Secretary Alex Azar on Monday told a crowd of kidney disease patients and advocates the Trump administration is overhauling Medicare's payment system to move the bulk of dialysis treatments from clinics to the home.

He touted an existing payment demonstration launched by the CMS Innovation Center under the Obama administration in 2015, which has the backing of the dialysis industry: the End Stage Renal Disease (ESRD) Seamless Care Organizations.

Medicare has an outsize influence on kidney care policy. Kidney disease accounted for more than one-fifth of all Medicare spending in 2016, or about $113 billion, and the program covers people under 65 who suffer from end-stage renal disease that can only be treated with dialysis or a transplant.

"Today, 88% of Americans with end-stage renal disease start treatment with center-based dialysis," Azar told the National Kidney Foundation audience. "Just 12% start treatment at home with hemodialysis or peritoneal dialysis. This is the complete opposite of the situation in some of our peer nations, including Hong Kong, where more than 80% of patients benefit from some form of in-home dialysis."

He added: "Heck, Guatemala is at 56% peritoneal!"

He criticized the current system as driving "center-based dialysis. The ESRD Seamless Care Organizations, or ESCOS, save Medicare about $2,000 per patient per year and reduce hospitalizations, he added.

"For one, we believe we may simply underpay for these (home) alternatives, even though we know how much they can benefit patients' lives," Azar said. "It's also more appealing for a dialysis company to add patients to a center where one machine can accommodate multiple patients than it is to provide new services to each patient at home."

Dialysis giant Fresenius Medical Care just won a victory in the home dialysis space last month, when the U.S. Federal Trade Commission voted 3-2 to approve the company's $2 billion merger with NxStage Medical., a hemodialysis machine manufacturer. The FTC dissenters were concerned the merger "could thwart other competitors from entering the home hemodialysis market," according to a report by Healio.

The merger closed Feb. 26 and the company said in a statement it believes it is "uniquely positioned to foster innovation in the interest of our patients and overall reduction of cost for the healthcare system."

The CMS Innovation Center Director Adam Boehler is working on new payment models for patients with stage 4 and 5 kidney disease as well as ESRD.

Azar's praise for the ESCO demonstration comes as Congress faces an unknown path forward for its controversial dialysis bill. Known as the Dialysis Patients Demonstration Act, the bill would let major dialysis companies like DaVita and Fresenius Medical Care assume full risk to treat ESRD patients. Critics say the legislation would almost exclusively benefit these two corporations. It failed to move forward in the last Congress.

In his speech, Azar also announced HHS is trying to boost the number of organs available for transplant across the country by identifying more organs safe for transplant, bringing more living donors into the system and spurring development of implantable artificial kidneys.

The scarcity of organs for transplant is an increasingly visible issue in Congress, where Senate leaders have probed HHS' decision to encourage an overhaul of the geography-based organ allocation issue.

Azar announced that next month the department will announce updated guidelines for identifying organs that could potentially transmit HIV or hepatitis B or C. The guidelines were last updated in 2013.

"Since then, the science has been advancing," Azar said. "We've been able to develop and analyze new data about our testing capabilities for HIV, hepatitis B and hepatitis C, and the kind of surety they can provide around organ safety."

To expand the network of living donors, Azar said HHS' Health Resources and Services Administration will continue a program that compensates donors for travel and other donor-related expenses, and launch a new pilot program to reimburse donors for lost wages.

In the meantime, the KidneyX initiative has also launched. This partnership between HHS and the American Society of Nephrology wants to drive development of wearable or implantable artificial kidneys.

The first round of submissions for the effort closed last week with 165 entrants, Azar said.