NN&I - June 2010

8 Nephrology News & Issues June 2010Subscribe to our free eNewsletter at www.nephronline.com Mr. Neumann has been editor of Nephrology News & Issues since 1989.FIRST WORDBy Mark E. Neumannthan Medicare). In his column on health care reform in last month's issue of NN&I ("Sweeping Medi- caid reform should positively im- pact CKD"), former Centers for Medicare & Medicaid Services pol-icy maker Brady Augustine said, "All persons either at risk or being affected by chronic kidney disease will have guaranteed access to cov-erage at affordable rates. This will go a long way to potentially averting CKD altogether." The health care reform law does offer up the opportunity for a great deal of potential goodaccess to CKD patients at earlier stages, opportunities to practice preven -tive care, improved vascular access management (implanting fistulas early), better nutritional counsel-ingand will create a patient popu-lation that is well prepared when residual renal function ends and dialysis begins. Finally, perhaps, all the efforts made by the National Kidney Foundation and the American Kidney Fund to offer screenings aimed at uncovering hypertension and early stages of diabetes can be linked to a provider and payer to address the problems. But it won't be that easy. Do we have enough health care \037 providers to care for all these new patients? Can we count on CMS and \037 Congress to develop new payment models that encourage aggressive preventive care, using well-designed accountable care organizations to coordinate care? It can't just be about pay-for-performance; offer the tools and autonomy to direct the care that is most effective, as well as efficient.Can we drag down the wall \037 between hospital payments and out -patient payments so that the incen -tives are aligned? As CMS adminis-trator nominee Donald Berwick says in his well-received quote, "The best hospital bed is an empty one." If renal providers make strong efforts to reduce hospitalizations and improve preventative care, incentives need to be offered. Let's not forget the patients. It's \037 fair to say that a good portion of patients end up in the emergency room getting their first dialysis treat -ment through a catheter because they lacked health care. But there is also a portion of patients who are in denial; they didn't want to hear the repeated suggestions to change their diet, they didn't want to have a fistula implanted early, or they didn't take modality education class -es. Optimal health care has to be a partnership.Ultimately, much work needs to be done for health care reform to bear fruit. Cooperation. Patience. Forward thinking. These will be required. The potential to do well rests on every -one's shoulders. Will health care reform put CKD in the spotlight?Thirty-two million Americans. That's the estimate for the num-ber of people who may become insured under the new health care reform lawor who have access to a health care plan that offers improved and more comprehensive benefits. The costs clearly will be staggering. New estimates from the Congressional Budget Office now place it at more than $1 trillion over the next decadea number that Congressional Democrats were hop -ing to stay under (previous estimates of $940 billion sounded a bit softer perhaps then using the T-word.)But supporters argue that the upfront cost of care may bear out a silver lining for major payers like Medicare: investing in preventive medicine and providing citizens with a complete package of well-ness services may save money in the long run. Individuals with chronic kidney disease fall into that category. Many of those 30 million people will likely end up getting insurance through a state-supported Medicaid program. That may not bode well for pro-viders (Medicaid always pays less FirstWord_NNI0610_3.indd 8 5/17/10 3:20:58 PM