Dr. Rishi R. Khatri, Esq.
Although not as popular a subject for cost benefit analysis as other diseases such as heart disease or diabetes, there is a ever growing population of patients with chronic kidney disease (CKD) who are developing end stage renal disease (ESRD). In 2009, overall Medicare expenditures for people with CKD totaled $33.8 billion. Of that total, expenditures for people with CKD and diabetes accounted for $18 billion. Also in 2009, Medicare spent $29 billion (6.7% of its total budget) on kidney failure. (US Renal Data System (2011). USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease. Bethesda, MD).
Diabetes and high blood pressure are major drivers of renal disease. Because of the increase in these causal factors, renal disease is consuming an ever-increasing percentage of healthcare expenditure, with the major payor being the United States government through Medicare. Part of the reason why the disease isn’t popularly recognized as a health care crisis is because the disease is underreported or missed generally by practitioners. At any rate, the need for more opportunities to lower the incidence of CKD and the cost of CKD management is necessary in order to save the system money. Although the solutions are complicated, there is data to support certain directions for the treatment of CKD and ESRD.
What is CKD, ESRD, and Dialysis?
Kidney disease occurs when the kidneys are no longer able to clean the blood of toxins. According to leading dialysis services provider, DaVita Kidney Care, the disease comes in five stages, with minor kidney disease being stage 1 which can then move to the worst kind of kidney disease, stage 5 (also known as end stage renal disease, or ESRD). Stage 5 is when kidneys function below 10 to 15 percent of their normal capacity. This essentially is known as kidney failure.
More so, kidney failure occurs after years of having chronic kidney disease (CKD). It’s vital that a person with kidney failure receives a kidney replacement treatment to stay alive. However, if there is no kidney transplant available for the patient, dialysis treatment can do the job of the kidney while the patient waits for a suitable donor kidney.
The treatment for someone with ESRD and CKD is dialysis. Dialyses is the clinical purification of blood by the separation of particles in blood on the basis of differences in their ability to pass through a membrane as a substitute for the normal function of the kidney.
What causes CKD?
Two things mainly: diabetes and high blood pressure. Both of these are epidemics in the U.S., setting up renal disease in many of these patients.
Diabetes causes 38.4% of all cases of kidney failure. In 2009 it was the primary causal diagnosis for 214,909 kidney failure patients. An estimated 25.8 million people have diabetes; 7 million of them are undiagnosed. About 40% of people with diabetes will develop CKD. (Centers for Disease Control and Prevention (2009). Leading Causes of Death. Retrieved from www.cdc.gov/nchs/fastats/lcod.htm).
High blood pressure (HBP) causes 25% of all cases of kidney failure. In 2009 it was the primary diagnosis for 139,910 kidney failure patients.
An estimated 73 million people have HBP; 31.6% of them are undiagnosed. As a sad commentary of this disease, most people (85%) participating in a 2011 nationwide survey by the American Kidney Fund could not name high blood pressure as a leading cause of kidney disease, yet most of them (75%) had a loved one with high blood pressure.
What is the Rate of Kidney Disease in the Nation?
Kidney disease is the 8th leading cause of death in the United States (Centers for Disease Control and Prevention (2009). Leading Causes of Death. Retrieved from www.cdc.gov/nchs/fastats/lcod.htm). An estimated 31 million people in the United States (10% of the population) have CKD. Moreover, 9 out of 10 people who have stage 3 CKD do not know it. CKD is more common among women, but men with CKD are 50 more likely than women to progress to kidney failure or ESRD). Kidney disease is a very serious public health issue indeed.
What to do?
As public health implications and economic burdens of kidney disease in the United States continue to grow, there must be new innovations to prevent the development of kidney failure in the first place, and to help those with kidney failure, thereby slowing expenditure on this health care issue. That said, there are new treatments and strategies being developed and deployed.
One of the easiest and most essential strategy lines to take in combating CKD is improving primary care services to avoid CKD in the first place. It has been found that primary care physicians' familiarity with chronic kidney disease is somewhat lacking. (Israni RK, Shea JA, Joffe MM, Feldman HI. Physician characteristics and knowledge of CKD management. Am J Kidney Dis 2009;54:238–47). Given these points, a primary care physician can make a significant impact in slowing the progression of chronic kidney disease through strict blood pressure control, tight glycemic control, reduction in the degree of proteinuria, and smoking cessation. Early screening and treatment of risk factors can prevent the development of kidney disease. Additional training and education about chronic kidney disease and its complications can help primary care physicians to directly impact and halt CKD progression.
While having a better educated primary care provider in regards to screening for disease risk factors is the best way to stop CKD, one very promising programmatic innovation in an attempt to reduce cost is a holistic program named Team Care, which started off as a pilot program through DaVita in El Segundo, California. Team Care is a collaborative effort which focused on integrating healthcare across various services, not just the dialysis units, and involved teams comprising clinicians, nurse practitioners, case managers, and pharmacists.
According to MedPage today, the program was able to reduce catheterizations, eliminate drug interactions, and increase vaccination rates, with more than 90% of patients receiving influenza and pneumococcal vaccinations.
The overall medical costs per member per year were 5% lower than fee-for-service programs in 2008, which wasn't significant, but they were a significant 10% lower in 2009 (P<0.01) and an estimated 11% lower in 2010 (2010 Medicare 5% data were unavailable so the researchers adjusted 2009 data to estimate the comparisons).
Inpatient costs with the pilot program were a non-significant 7% lower than Medicare 5% data in 2008 and a significant 18% lower in 2009 (P<0.0001), as well as an estimated 18% lower in 2010.
As the incidence of renal diseases CKD and ESRD rise due to the increase in causal conditions like diabetes and hypertension, prevention and management of the drivers of CKD as well as integrated management of patients who have established CKD will decrease the financial burden on our healthcare system. It is critical that we not just focus on the kidney, but a person’s overall health through primary care and integration of services. This approach has seen real world cost savings and can be implemented at any center treating kidney disease.