The Evolving Nephrology Landscape: Treatment, Innovation, and Policy: Part 3
Key Takeaways:
- Early identification and treatment of chronic kidney disease (CKD) remain underutilized despite strong evidence of benefit. Appropriate screening of at-risk populations, timely nephrology referral, and use of proven therapies—including RAAS inhibitors, SGLT2 inhibitors, and GLP-1 receptor agonists—can slow disease progression and reduce cardiovascular complications.
- Most kidney failure is linked to treatable conditions. Approximately 75% of patients initiating dialysis have diabetes or hypertension, underscoring the importance of aggressive risk-factor management and coordinated care to prevent progression to end-stage kidney disease.
- Access to innovation and home-based care requires supportive reimbursement policies. Expanding home dialysis, remote patient monitoring, and next-generation kidney technologies will depend on payment models that encourage adoption while ensuring equitable access across rural and underserved populations.
In part 3 of our interview with Suzanne Watnick, MD, she discusses opportunities to improve CKD outcomes through earlier screening, evidence-based treatment, and better access to innovative therapies. She also explores the role of payment policy in supporting home dialysis, remote patient monitoring, and emerging kidney care technologies while addressing disparities in access and outcomes.
How might sustainability and innovations in home dialysis shape future reimbursement strategies and care delivery decisions?
Suzanne Watnick, MD: Since we're just talking about the Ways and Means Committee testimony, I'm going to continue with that and move on to other areas. Specifically, we were asked questions during that hearing about access to home dialysis.
Making sure that people had access, whether they were in rural or non-rural environments, was critical.
One of the congressmen specifically asked about making sure that dialysis facilities were available for whatever option a patient chose if they needed dialysis. There was also legislation about to be introduced related to remote patient monitoring, or telehealth, to ensure that patients had access.
If you think about it, if you're in a very rural area and you're 100 miles from the nearest dialysis facility—which we don't usually think about because, in urban or suburban areas, it's typically much closer—it can be incredibly difficult. If you have a 7 am. dialysis appointment 3 times a week, you may have to wake up at 4 am.
As I mentioned earlier, dialysis really is a part-time job that nobody wants. It takes a lot—not just from the individual in terms of the burden of travel, but from their entire care community. Whoever their care partner might be has to help with transportation and caregiving, which affects their lives as well. How can that person who is on dialysis, or their care partner, work if the care partner has to transport them? It's important that we think about access.
In terms of new ways of doing home dialysis, it would be great if a higher percentage of people chose that option so there isn't such a burden on individuals to leave home so frequently. Again, talking about research and innovation, we need to make sure that people have access to innovative therapies. First of all, those therapies have to exist, so funding is critical. Some groups have created new systems, but then the question becomes: How can those new systems—such as wearable dialysis, portable dialysis, or updated dialysis technologies—get to patients?
Again, this comes back to policymakers and making sure that new and innovative equipment, supplies, and devices have a pathway for reimbursement. In Medicare fee-for-service, for example—which covers about 40% of dialysis patients in this country, while Medicare overall covers about 80%, with the other 40% covered through Medicare Advantage arrangements—there is a mechanism for a transitional add-on payment for new and innovative equipment and supplies.
However, that mechanism has not been well utilized since it was introduced nearly 5 years ago. Only one device has received access to that add-on payment, which is intended to help people afford innovative therapies. Right now, dialysis is paid for through a bundled payment system. For those outside the kidney care space, the ESRD Prospective Payment System uses a bundled payment for everything related to dialysis except the physician fee.
When you have a bundled payment, it does not incentivize dialysis organizations to pay for new or innovative equipment, which may understandably be more expensive than older equipment and supplies. For all of these strategies and care delivery decisions, you need a payment mechanism.
Private insurers often follow Medicare's lead and also pay a bundled rate. As we move forward, we need to think about how to bring in payment systems that may or may not be cost-neutral. Right now, everything has to be cost-neutral, meaning that if you pay more for one thing, you pay less for something else. That does not incentivize innovation or getting new technologies to the patients who need them.
Walking into a dialysis facility—or even doing home dialysis—doesn't look tremendously different from what it looked like 30 years ago in the 1990s, and that's a travesty.
Watch all parts of the interview here:
