The renal community has complained for years that the Medicare dollar isn’t enough to treat the increasingly complex individual with kidney disease. As much as price gouging the commercial payers seems a twisted way of cost shifting, it’s necessary to keep the books balanced, dialysis providers say.

And that’s just for what many acknowledge is just “adequate” dialysis: three times a week for 3-4 hours. Most accept that this 1980s-era formula doesn’t provide optimal clearance. Then, it was: build a center, add dialysis machines, develop a schedule for patients, run three shifts a day. Thrice weekly seemed like a good fit for that business model.

An indecent proposal

So what if you could re-engineer that dialysis prescription, and you got $30 million to do it? Renal Ventures Management nephrologists who attended their company’s medical director’s meeting in September went through this exercise, and at the recent program for medical directors held by the National Renal Administrators Association at their annual meeting in Chicago, the attendees got their own opportunity. Speaker Allen Nissenson, MD, the chief medical officer for DaVita Healthcare Partners, was part of the Renal Ventures Management program and brought the challenge to the NRAA conference attendees.

If you had $30 million, how would you improve the care of dialysis patients in the United States?

I have an idea

Nissenson gave NN&I some of the ideas from the RVM meeting, and together with the NRAA attendees, helped us put together the list of ideas from both groups. Here they are, in random order:

  • Set up a nocturnal hemodialysis program for pediatric patients
  • Develop patient rewards/incentives to attain good outcomes
  • A nurse for every patient (while extending respect to many patient care technicians who also provide great patient care)
  • Set up a fair and well-regulated payment system for acquiring kidneys for transplant
  • Improve techniques and options for the vascular access
  • Improve IT connectivity so outpatient staff can communicate better with hospital staff about the welfare of the patient
  • Add a person to each facility to do coordinated care management
  • Promote and expand home dialysis programs; offer paid staff assistance
  • Focus on CKD education
  • Have a CEO in every facility (Catheter Elimination Officer)
  • Form a transportation service to get patients where they need to go, such as medical appointments, grocery shopping, trips to the pharmacy, support groups meetings, etc.
  • Develop stronger partnerships with vascular surgeons, perhaps with financial incentives to put in the favored access type
  • Expand the use of nutritional supplements
  • Develop palliative care/end-of-life care programs
  • Provide volume monitoring equipment for all patients for home use

These are great ideas focused on making quality of life improvements for patients. And we would like to hear about more. Send me your thoughts at, or leave a comment on our website.

What can we do right now?

Nissenson pointed out that some of these ideas are already underway and we have tools to develop others. The Renal Physicians Association and the ESRD Networks have developed guidelines to help patients who need end-of-life care. There are greater efforts focused on CKD education, but coordinating preventive care aimed at delaying ESRD needs more collaborative referrals, better insurance coverage, and even patients’ acceptance that they are sick.

I like proven concepts like staff-assisted home dialysis and offering nutritional supplements. Those are positives that should be implemented. Volume control is the next big push for the renal community; the key is patient engagement and staff vigilance. “We need to work on this together” must be the mantra.

IT improvements are also important if we want to improve outcomes; clean data that can be shared is an important component.

Changing our approach to vascular access? Poor access choices lead to deadly infections. We need fresh ideas on how to control this problem.

We don’t need $30 million to fix these problems, “What matters is what is really important to patients,” Nissenson told the NRAA conference attendees. “We did extensive interviews with patients and asked what is important to them. It turns out it wasn’t what was important to nephrologists or to CMS. The number one thing: ‘I want quality of life.’ “

Sounds simple enough. Let’s get to work.