Medicare Payment Rule Threatens Access to Life-Sustaining Kidney Care

Nationwide, the kidney care community faces myriad problems that are stretching resources thin and undermining patient access to care. As in many other health care sectors, the past several years have seen a growing workforce shortage among dialysis providers and nephrology registered nurses (RNs). High rates of burnout, an aging workforce, and the economic impact of the pandemic are all contributing factors to the dire situation kidney care professionals are confronting. Moreover, dismal reimbursement rates outlined in the End-Stage Renal Disease (ESRD) payment final rule will only further stress an already fragile system of care.

Meanwhile, the demand for dialysis services continues to grow. Chronic kidney disease (CKD) is the fastest-growing noncommunicable disease in the country and currently impacts nearly 40 million American adults. If CKD progresses to kidney failure, known as end-stage renal disease or ESRD, individuals must receive regular dialysis treatments or a kidney transplant in order to survive. Given that the population of individuals with kidney disease is growing by an estimated 5% to 7% each year, dialysis clinics will continue to be an essential piece of our nation’s kidney care infrastructure.

A shortage of healthcare professionals and an increasingly high demand for care is a dangerous mix. We’ve seen already that workforce shortages are hindering dialysis clinics across the country by forcing them to reduce shifts or even close their doors entirely, often in rural or otherwise medically underserved areas. Despite this, CMS’ payment increase is substantially lower than rising costs, particularly the high labor costs for specialized nephrology RNs and other personnel who play a vital role in delivering high-quality, timely and life-sustaining kidney care. As advocates pointed out in a recent letter to CMS, an analysis of the agency’s own data on dialysis providers’ labor-related costs saw a rise of 7% from 2018 to 2022, while the market basket increase assumed a rate of just over 3%. Because Medicare is the payer for nearly 80% of all dialysis patients, when Medicare fails to adequately address costs there is very little backstop of other payers to prop up the system until Medicare catches up.

The gap between the cost increases dialysis providers face versus what CMS is reimbursing them for directly and negatively impacts the ability of dialysis providers to adequately staff their clinics, ultimately impacting access to care. We have seen a significant loss of experienced staff and mentors, making it very difficult to foster growth of new staff that are just learning this specialty and the unique needs of individuals on dialysis. Safety and quality are getting harder to maintain as the focus of care is strained and limited to basic task completion.

These labor challenges will be particularly devastating to medically underserved rural and urban communities, forcing patients to travel hours for care because their local clinic has closed. It is also forcing patients to change established schedules and go to available treatments on sporadic or alternate days, significantly impacting their daily lives or ability to work and plan. There are even documented reports of patients losing their jobs specifically because of an incompatible dialysis schedule.

In the face of these challenges, CMS has failed to address the fact that its own assumptions used to set the annual payment update have been wrong during the last few years. As it does for skilled nursing facilities, CMS should increase the update factor to include the actual inflationary increase when their own estimates are incorrect. We also encourage Congress to pass the bipartisan Chronic Kidney Disease Improvement in Research and Treatment Act (H.R. 5027) to address the underfunding of ESRD services in order to help clinics become competitive to attract and retain top talent, invest in training and innovative treatment options, and continue providing high-quality care.

By working with the kidney care community to mitigate the cost of attracting and retaining skilled nephrology RNs and other kidney care professionals, policymakers can help expand, instead of restrict, access to vital dialysis services for millions of Americans.

Author Information

Jennifer Payton, MHCA, BSN, RN, CNN, is president of the American Nephrology Nurses Association (ANNA) and John P. Butler is former chair of Kidney Care Partners and CEO of Akebia Therapeutics.