In today’s era of sensitivity to health and healthcare costs, one frequent topic of discussion is the healthcare cost of managing End Stage Renal Disease (ESRD).
In 2014, the Centers for Disease Control and Prevention (CDC) estimated that more than 20 million people in the U.S. (or as much as 10% of the U.S. population) may have chronic kidney disease and that number is growing. To manage healthcare costs, insurers must understand the scope of the disease as well as recognize the importance of optimal contracting, claim review, disease management and advocacy.
ESRD is an irreversible decline in kidney function requiring ongoing dialysis or kidney transplantation to sustain life. The effects for a patient with ESRD are severe and the aggregate costs of ongoing dialysis, recurrent hospitalizations and treatment of co-morbid conditions can overwhelm both patients and our clients.
The kidneys are multi-purpose organs whose primary function is to remove waste and excess water from the body while managing water levels, maintaining the balance of minerals and vitamins, and ensuring a normal blood acid balance. Kidney disease or disorders can damage the kidneys, impairing their ability to function.
There are two types of kidney failure; acute and chronic:
Acute kidney failure is the sudden loss of kidney function. It is most common in those who are already hospitalized, critically ill and in need of intensive care.
Chronic Kidney Failure (CKF) is often first detected by screening individuals who are at high risk, including diabetics and individuals with high blood pressure or a family history of CKF. Screening for CKF includes measuring kidney function by assessing glomerular filtration rate (GFR). Individuals with a GFR less than 60 mL/min/1.73m2 are classified with chronic kidney disease regardless of whether there is kidney damage. Once an individual reaches stage 5 chronic kidney disease, the condition is then considered ESRD.
A common cause of ESRD is diabetic nephropathy. Other causes include high blood pressure, autoimmune diseases, genetic diseases, infection, drugs, traumatic injury, major surgery and nephrotoxic poisons.
Early identification and aggressive disease management is key in managing chronic kidney disease prior to end-stage kidney failure. Diabetes, congestive heart failure and chronic kidney disease are associated with the highest population-level expenditures in Medicare and commercial populations. An aggressive disease management program provides interventions that are focused on the specific health challenges facing mid to late stage kidney disease patients and addresses the major drivers of hospitalization and dialysis costs. Because of all the complicated comorbidities, these patients need specific management plans and complex care coordination across multiple clinical specialties.
For patients that progress to ESRD, three treatment options are available; hemodialysis, peritoneal dialysis, or kidney transplant.
Although significant gains have been made in dialysis therapy, patients with ESRD confront major challenges such as high mortality rates and high costs associated with the initiation of dialysis, which often occur in an inpatient setting. Risk factors associated with increased morbidity include cardiovascular disease, hypertension, diabetes, infection, bone disease, anemia and malnutrition. The survival rate of hemodialysis patients three years after the start of therapy is only 52 percent. In contrast, the three year survival rate for individuals that receive a kidney transplant is 92 percent.
Offering transplants across the board isn’t as straightforward as it might seem. Why?
There aren’t enough donor kidneys to go around. A new kidney may come from a living donor (related or non-related) or from a deceased donor. Patients typically do better if they receive a kidney from a living, related donor. But when a living donor isn’t available, patients register with the United Network for Organ Sharing (UNOS) to be placed on a waiting list for a cadaver kidney transplant.
There is a shortage of donated organs and the waiting list is growing. According to the National Kidney Foundation, as of September 2014, there were 101,170 people on the waiting list in the U.S. However, in 2013 there were only 16,896 kidney transplants in the U.S. Of those, 11,163 kidney transplants came from deceased donors and 5,733 came from living donors. The average wait time for a kidney is over two years.
Detailed screening is critical. Given the scarcity of available organs and the fact that many patients are older and sicker, potential candidates must be carefully screened for compatibility and to detect and treat coexisting illnesses that may affect their suitability for transplant, perioperative risk, and survival after transplantation.
Advocacy – Dialysis costs can be staggering. In some cases they are as high as over $1 million per individual per year. In 1982, Medicare Secondary Payer Provisions of the ESRD program were articulated. Under this program, ESRD benefits are coordinated between Medicare and private health insurance plans, and currently, the private health plan is the primary payer for the first 30 months of treatment. With the assistance of our advocacy partners, PULSE + Plus™ works with our clients to ensure that eligible members are enrolled in the Medicare ESRD program.
Contracting – Aside from advocacy, contracting is the most important aspect of mitigating dialysis cost. Obtaining an all-inclusive case rate for the dialysis treatment including the ancillary/pharmacy charges that are typically prescribed by the physician, is the preferred methodology versus a percentage off of billed charges. If an all-inclusive rate is not possible and a percentage off of billed charges is maintained, then it’s particularly important to monitor dialysis claims for potential inappropriateness of charge.
Appropriateness of Billing – Under the current single-payment billing system, payers may see consolidated billing that includes a variety of equipment, services, and supplies from multiple providers. Thus, detailed billing analysis is essential along with contract language to support this review. Fortunately, PartnerRe’s PULSE + Plus™ Program can help. We assess cases to validate treatment plans, contracts and billing appropriateness.
Consistency and Vigilance – When you have exceptional, aggressive disease management processes in place, an optimal contract and a claims review process to ensure only appropriate and eligible charges are considered, this can result in dramatic savings for both the insurer and patient.
Contact the experts at PartnerRe for more information.