With average annual dialysis charges topping $475,000, it's easy to understand why programs that directly address dialysis costs have become so popular. What is less understood is by the time one starts dialysis, the proverbial horse has already left the barn and the opportunity to help members defer dialysis has been lost.
At that point, all that can be done is to cut the losses.It is not well known that Chronic Kidney Disease (CKD) can be managed and dialysis delayed (a recent study refers to the word "remission"1 vs. delayed); for some, indefinitely. As a 2005 article in the American Family Physician states, "Evidence suggests that the progression to kidney failure can be delayed or prevented.
Unfortunately, chronic kidney disease often is overlooked in its earliest, most treatable stages." 2Why is this fact hidden? Dialysis bills ARE the huge red flags, but the lesser CKD bills rarely catch the analyst's attention. Avoiding dialysis creates 100 percent savings, not a discount off charges which, I suggest, is more important and absolutely measurable.
Recent studies indicate that additional costs accrue when members suffering from existing chronic conditions develop CKD with the medical spend on those related diseases increasing, sometimes doubling.3 CKD progresses in stages.
As the disease progresses, medical spend goes up. Costs increase for care of the CKD and for the underlying chronic illnesses. If the progression of CKD is slowed, the expense of dialysis can be delayed or avoided and the cost of chronic diseases reduced. For members, this also means an improved quality of life and lower absenteeism.
With such complex interactions between comorbidities and renal disease, how can the savings be realized? By looking at specialized disease management and wellness activities that focus on CKD AND the related diseases, that's how. This comprehensive approach for the sickest and most expensive members can reduce spending for care now and avoid future costs.
Many of the interventions involve lifestyle changes, others medical and medication management. Most are low-cost, high-reward interventions. Education is also key in providing members the information to make the right decisions. One indication that insufficient attention is paid to managing CKD is that approximately one-half of those members who advance to dialysis are not aware of their CKD diagnosis until an acute episode leads to the initiation of dialysis.
Studies indicate that dialysis costs are significantly reduced and healthcare quality increased if nephrology care is accessed at least one year prior to dialysis. If one-half of this population isn't aware of their CKD, they don't have the opportunity to receive this care, preplan for fistula placement or take steps to educate themselves on low-cost, high-quality treatment alternatives such as home dialysis.
Once conventional dialysis is begun, members find it very difficult to switch to home modalities even though their quality of life could be improved by such a change. A 2000 journal article points this out and makes points still pertinent today: "The available evidence strongly suggests that early referral can improve the short- and long-term survival of uraemic patients; facilitate the management of comorbid conditions; provide the time necessary for patient education, creation of dialytic access and appropriate initiation of dialysis; help preserve adequate nutrition and biochemical parameters; reduce hospitalizations and influence the selection of dialysis modality."4
For information on the many benefits of home dialysis we recommend visiting the non-profit education site, www.homedialysis.org. So, why are employers and payers not keenly aware of CKD? First and foremost, while there is a simple test for CKD, it is not administered nearly as often or widely as it should be.
Even many physicians believe the myth that the progression of renal disease cannot be influenced by treatment. This belief persists in spite of a plethora of research showing that, in many cases, progression of CKD can be significantly slowed by comprehensive management of the disease and comorbidities.
CKD, as noted earlier, is typically caused by other chronic conditions and those conditions often receive coding superiority and care focus. CKD costs may appear relatively low if the cost multiplier and the volume of undiagnosed cases are not considered. The essence is CKD is a "hidden" disease that adds complication and cost to other expensive and complex chronic conditions.
Unfortunately, few members access comprehensive care at an early enough point to reduce morbidity and costs. The presence of so many silent CKD members (the members who are not aware of their CKD diagnosis) leads to increased costs and reduced quality and quantity of life.
Early diagnosis and aggressive management results in educated members who understand all of the available choices should dialysis become a necessity. Education and support can offset some of the bias towards traditional in-center dialysis and its medical dependence, thus giving members charge of their lives.
In the words of an old car care commercial, "you can pay me now, or pay me later." Later costs more, reduces the ability of employees to be present and often shortens life expectancy. Managing CKD and its related chronic conditions can seem overwhelming; however, employers utilizing specialized CKD intervention tools, wellness programs, specialized CKD disease management programs and educational services in a controllable high-cost population can give back to their members while saving money, a win for all.
About The Author
Robert Kellerman, MSW, MBA is Vice President, Business Development at Renalogic is responsible for development of product concepts, national sales and partner relationships. He has over 30 years of experience in healthcare and healthcare cost containment including provider contracting with a major Blue Plan, hospital and clinic administration, marketing and sales.
Jay Ginsberg received his MD from Thomas Jefferson University. Following an internal medicine residency and a nephrology fellowship he began a private practice of Nephrology in Connecticut. In 2010 Dr. Ginsberg earned a Masters in Medical Management. He currently serves as Medical Director of Renalogic a Renal Disease Management Company.