Here is part two of a review of the important kidney care issues on the political and policy front from this past year. If I missed something, let me know about it. (For part one, click here)

The (CROWN) Web we weave
The first in a series of deadline extensions in 2012 for the impending launch of the CROWNWeb data collection system was announced March 1. That despite months of pilot testing and a renal community sharing its list of technical problems. More extensions took the national launch date to June 14, and extensions have followed since for dialysis providers to enter patient data. The latest CMS directive relaxed a Nov. 30 deadline after the agency heard complaints from the community about system-oriented failures.

"Wonder drug" goes under the knife – revisited
 While data analysts continue to monitor the drop in Epogen use, they also have picked up on a trend in increasing transfusions. That could signal a swing of the hemoglobin pendulum too far: dialysis providers may be pushing below the "floor" of good anemia management––most in the renal community agree that hemoglobins below 10 g/dL are not optimal for patients––by cutting doses and sending anemic patients to the hospital. CMS decided to drop the lower range for hemoglobins as a punitive measure in its Quality Incentive Program for payment year 2014, but kept the higher range––greater than 12 g/dL––intact. That gave providers the incentive to lower both the top and the bottom range, but caregivers on the front lines were facing questions by patients who liked their high hemoglobin levels––the ones that were tied to reduced payments to the facility––and by other patients asking how low can we go. "As a patient, I am concerned that eliminating the lower boundary for assessing the quality of care for anemia management will lead to a significant decrease in Hgb levels and increase the percentage of patients requiring transfusions.," wrote patient advocate Lori Hartwell in her June 2012 editorial, "I want to be at least a 10."
Died: George Rathmann, first CEO of Amgen Inc.; Dimitrios Oreopoulos, MD, pioneer of peritoneal dialysis

Is there really no place like home?  
The dialysis community has struggled for years to justify the sub-10% number of the U.S. dialysis population that receive dialysis at home––either peritoneal dialysis or some duration of home hemodialysis. Incentives created in the payment bundle in 2010 have stimulated some growth. We looked at data from NN&I’s annual dialysis provider survey, and found that more new patients in 2012 were deciding to dialyze at home. Among the 10 largest providers, 35,535 patients were dialyzing at home last year, up from 26,728 in 2010. The impact of NxStage Medical cannot be denied; the company has more than 5,000 patients on its SystemOne home dialysis machine. Other hemodialysis machines geared for home use are being developed by Baxter, Home Dialysis Plus, and we may see some European entries as well in the near future.

Died: Gary Brukardt, first CEO of Renal Care Group

Neither (hurricanes), nor sleet, nor snow
The National Weather Service uses first names in alphabetical order to list weather systems––Hurricane Neil, Katrina, Ike, Anna––but describing the impact of what the storms produce could take on a whole new language. In a storm, dialysis facility operations are vulnerable; they need fresh water and electricity to keep machines humming. If either one of those sources is not available, there is no dialysis. Hurricane Isaac, which threw a scare at the Republican National Convention in Tampa before knocking out power for more than 750,000 residents in Louisiana and Mississippi in August, put dialysis providers in disaster mode. Fresenius Medical Care had to close 150 clinics for varying time intervals during the two-day storm, and DaVita did the same for 29 of its clinics. The flooding impacted over 12,000 patients; New Orleans, learning lessons from Hurricane Katrina, evacuated thousands of its own residents. But dialysis providers, with the help of organizations like the Kidney Community Emergency Response Coalition, kept their cool by dialyzing patients before the storm hit, making sure clinics had working back-up generators, keeping communication lines open with patients, and making sure staff were accounted for. "A few teammates had to leave their homes; one had to be rescued with four kids in Plaquemine Parish" in New Orleans, said DaVita Village Emergency Response Team member Shelly Bradsell. "We helped her out with clothing; other teammates were placed in hotels."

Little did they know that Hurricane Sandy would pay a visit just a few months later.

Died: Joseph Murray, MD, performed the first human kidney transplant.