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Presidential Executive Order about Kidney Care - July 2019

Kidney Care Presidential Order

Specialties Urology Article News   posted

Specializes in Nephrology, Cardiology, ER, ICU.

We all know costs for nephrology patients continues to increase and numbers of renal patients continues to increase also. President Donald Trump has recently signed a proclamation which has possibly far-reaching consequences.

Presidential Executive Order about Kidney Care  - July 2019
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Many people in the US have some degree of renal impairment. The Centers for Disease Control (CDC) estimates that 15% or 37% of adults have chronic kidney disease (CKD). It is the 9th leading cause of death in the US. Here are some more sobering statistics:

  • CKD is more common in people aged 65 years or older (38%) than in people aged 45–64 years (13%) or 18–44 years (7%).
  • CKD is more common in women (15%) than men (12%).
  • CKD is more common in non-Hispanic blacks (16%) than in non-Hispanic whites (13%) or non-Hispanic Asians (12%).
  • About 14% of Hispanics have CKD.

What Are The 2 Main Causes Of All-Renal Disease?

We know the two main causes of all-renal disease are hypertension and diabetes. Unfortunately, both diseases can go unnoticed for many years before a diagnosis is made and treatment started. By then, sometimes the damage is already done. And as CKD advances, more complications occur:

  • Anemia or low red blood cell count (can cause fatigue and weakness).
  • Low calcium levels and high phosphorus levels in the blood (can cause bone problems).
  • High potassium levels in the blood (can cause an irregular or abnormal heartbeat).
  • Loss of appetite or nausea.
  • Extra fluid in the body (can cause high blood pressure, swelling in the legs, or shortness of breath).
  • Infections or a weakened immune system
  • Depression.

In reaction to this growing epidemic, Presidential Donald Trump signed an Executive Order outlining concrete steps that the US is going to take in order to reduce the number of patients with CKD. This mandate will also offer more choices for patients who progress to end-stage renal disease (ESRD) and must then rely on dialysis or a transplant to live. Some of the points include:

  • Preventing kidney disease through improved diagnosis and treatment of underlying conditions
  • Increase affordable treatment options and provide education for patients and encourage the development of artificial kidneys
  • Increase access to kidney transplant by modernizing the transplant system and updating counterproductive regulations

How Will We Reduce The Number Of Patients With Chronic Kidney Disease (CKD)?

And how will all of this get accomplished? There are multiple steps in this process and it isn't expected to be a quick solution to a growing problem.

  • Medicare will be testing payment options to increase preventative care and the use of home dialysis modalities and transplants
  • The President is enacting Congress to increase research and development of artificial kidneys
  • Streamline and expedite the matching of kidneys for transplants

So had does this Executive Order affect US - those caring for the renal patient on a daily basis? For this, I went to the Renal Physicians Association for their review.

  • A kidney disease awareness campaign is to be launched by the Health and Human Services (HHS) Department within 120 days (mid-November).
  • The Secretary of HHS must develop within 30 days a model which would “broaden the range of care and Medicare payment options available to potential participants with a focus on delaying or preventing the onset of kidney failure, preventing unnecessary hospitalizations, and increasing the rate of transplants. It should aim at achieving these outcomes by creating incentives to provide care for Medicare beneficiaries who have advanced stages of kidney disease but who are not yet on dialysis." (Quote from Executive Order)
  • Create payor incentives for home therapy modalities
  • The Food and Drug Administration (FDA) must consider requests for premarket approval of wearable or implantable artificial kidneys and to produce a strategy for encouraging innovation in new therapies
  • HHS is directed to revise within 120 days Organ Procurement Organization (OPO) rules and evaluation metrics to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO's performance. Additionally, within 180 days, the Secretary is required to streamline and expedite the process of kidney matching and delivery to reduce the discard rate
  • Formulate plans to provide financial assistance for living organ donors, specifically stating “the regulation should expand the definition of allowable costs that can be reimbursed under the Reimbursement of Travel and Subsistence Expenses Incurred Toward Living Organ Donation program, raise the limit on the income of donors eligible for reimbursement under the program, allow reimbursement for lost wage expenses, and provide for reimbursement of child-care and elder-care expenses.” (Quote from Executive Order)

There will be incentives for nephrology practices as well as for dialysis providers to meet these deadlines. However, this is a formidable task.

This will benefit nurses too. Nephrology nurses and advanced practice providers can expect new roles to come out of this initiative. Some of these might include:

  • Expanded nurse educator roles
  • Advanced practice providers will expand to providing more in-office CKD and ESRD education as well as transitional care visits
  • More nurses needed for home modality teaching and surveillance
  • Opportunities for pre- and post-transplant patient care will increase

What are your thoughts? Do you think the timeline is realistic?

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I think it’s fairly realistic. CKD is a huge problem so it’s nice that the focus is starting to shift towards prevention as well. I like the living donors incentives too. I will be interested to see how that comes to fruition. On a different note... I think it’s going to be real interesting to see how ans when Hospitals and insurance companies start posting prices. I read that for each day they don’t comply they are fine something like 500$.

I think it is realistic. But I'm concerned about insurance. My husband had to change from Humana back to regular Medicare. I tried to get a supplement and the first question was any kidney problem, told he didn't qualify for supplements

If he has ESRD he should be able to get a Medicare supplement,

Mr. Southern NP, MSN, RN, NP

Specializes in Nephrology/Hemodialysis.

I think the goals and timeline are a little lofty, but not necessarily a moonshot. I think it's a good start and a huge step in the right direction. One of the nephrologists in our area has already been doing everything he can to keep CKD patients from having to start dialysis (a rarity in the industry and really the only one in this area). He also tries to make sure that his patients are at least started in the process of getting a permanent access placed if they look like they are going to have to start dialysis. He will occasionally send us a patient that already has a permanent access in place. Unfortunately, as I'm sure you know, many nephrologists don't care to put in the work to keep a patient from progressing to ESRD and going on dialysis.

Hopefully these changes will be the start of a transition in kidney care for our country. It seems like it might make my position even more valuable at a nephrology practice once I finish NP school in December. Will definitely be educating myself on the policy changes, etc., so I can market myself well.

I worked in dialysis for four years. I do know that prevention was always on top to prevent CRF. Hopefully, President Trump realizes that if he tries to reclassify any of the diseases associated with CRF, medicare may not pay for the HD or PD treatment.

Nurse Beth, MSN

Specializes in Med Surg, Tele, ICU, Ortho.

Thanks for sharing. Very interesting


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