Hand and arm receiving hemodialysis

Surgeon Welcomes Shakeup in Kidney Dialysis and Transplant System

By on 07/17/2019

An executive order signed last week by the president outlines changes in the system of care for chronic kidney disease. The changes are intended to reduce reliance on dialysis by encouraging prevention of end-stage renal (kidney) disease and expanding the pool of organs for transplant. They would also make it easier for patients to receive dialysis at home.

The system is overdue for significant changes, says Radi Zaki, MD, Co-Chair, Department of Digestive Disease and Transplantation. “I think it’s something that needs to be done and the system needs to be shaken up.”

Dr.  Zaki identifies three major problems with the current system:

  • Insurance reimbursement practices that pay kidney specialists (nephrologists) more for treating patients who are on dialysis than for those who have less severe kidney problem and don’t yet need it
  • Poor performance by some of the regional organ procurement organizations (OPOs) that coordinate collection of organs from donors and distribution to people on waiting lists
  • Current policies that discourage home dialysis, which is common in Europe, in favor of treatment in large, for-profit dialysis centers

The result, Dr. Zaki says, is far too many people on dialysis, where most of them remain until death because of a shortage of kidneys for transplant.

According to the president’s executive order, issued July 10, about 20% of people beginning dialysis die within a year and 50% within five years.

Radi Zaki, MD
Radi Zaki, MD

Nearly 100,000 Americans are on the waiting list to receive a kidney transplant. But only about 20,000 people a year receive them, according to the U.S. Renal Data System.

“We should try to increase their rate of transplant for those patients, to get as many people off dialysis as possible or prevent them from ever having it,” Dr. Zaki says.

The order aims to help delay or prevent kidney failure and increase transplants. Specifically, it directs the Department of Health and Human Services to do the following:

  • Change the way that doctors are reimbursed in order to encourage “care for Medicare beneficiaries who have advanced stages of kidney disease but who are not yet on dialysis.”
  • Revise Medicare reimbursement practices to encourage home dialysis or transplants, rather than use of dialysis centers.
  • Create a new system for evaluating the performance of OPOs, which operate under contract with the U.S. government.
  • “Streamline and expedite the process of kidney matching and delivery” to reduce the number of organs that are donated but discarded.
  • Expand reimbursement of expenses in order to encourage more people to become living kidney donors.
  • Encourage innovations in kidney research and treatment, including development of an artificial kidney.

Since the 1970s, Medicare has covered people of any age who have end-stage renal disease, in which the kidneys are permanently unable to do their job of cleaning the blood. Someone with this condition needs dialysis or a new kidney. Medicare also covers Americans age 65 or older, who have a higher risk of kidney disease than younger adults or children.

For these reasons, Dr. Zaki says, Medicare’s policies can have a major impact on treatment of chronic kidney disease by changing how doctors are paid for different types of care.

One example: “Now they reimburse the nephrologists more to take care of dialysis patients than they do to take care of a patient who has renal disease and is not on dialysis,” he says. The new executive order proposes to reverse that practice and also to encourage transplants.

Another potential change would be to use home dialysis. There are two types of dialysis. Hemodialysis passes your blood through a machine that uses a filter and a cleaning fluid to remove wastes from your blood. Peritoneal dialysis doesn’t use a machine. You put cleaning fluid into your belly and then later drain it after it has absorbed wastes from the blood.

Both types can be done at home, but most people in the United States go to a dialysis center and receive hemodialysis.

“Home dialysis has definitely been shown to be better in terms of your quality of life and patient care,” Dr. Zaki says.

Another change proposed in the executive order is to have stricter standards for performance of the OPOs. This is greatly needed, Dr. Zaki says.

Some OPOs don’t do nearly as good a job of procuring organs for transplant as others, he says. The Philadelphia organization, the Gift of Life Donor Program, “has some of the greatest numbers of donors in the country,” he says, while some cities lag behind.

Discrepancies in the number of organs available from region to region led to rule changes adopted last year by the United Network for Organ Sharing, the governance organization for OPOs. The new rules say that the sickest patients within prescribed distances – up to 500 miles – have first preference for organs that become available. Previous rules favored keeping the organs within the same region.   

Rule changes like these amount to “robbing Peter to pay Paul” and don’t address the main problem of not enough donated organs, Dr. Zaki says.

But he said the changes in the president’s executive order are welcome. “So far, it’s been small changes here and there, or some radical changes that are not based on the main target of increasing the number of patients transplanted instead of redistributing the organs,” he says.

The new order takes aim at the real problems, he says. “I think it’s proposed to stimulate the number of organ donors and to shake up the OPOs so that they perform adequately and fulfill their mission.”

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