The growth in the number of patients with end-stage renal disease (ESRD) has tapered and is being offset by continuous improvements in survival.

The result is a continued steady increase in the number of patients requiring renal replacement therapy. The current national economic crisis reinforces the fact that although ESRD patients represent less than 1% of all Medicare patients, they consume more than 7% of Medicare dollars.

Hospital use has been falling but is still disproportionately high due to the high burden of illness among CKD patients. In-patient expenditures are driving most of the high cost of essential care.

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The ESRD program has been an entitlement for more than 35 years, but today’s care delivery and financing paradigms have changed little since the 1970s. Care continues to be delivered by multiple providers in disparate locations. There is poor communication among providers. Transitional care is poor, particularly the movement of patients in and out of the hospital. Patients require 7-10 medications per day. The list goes on.

On the financing side, the segregation of Medicare Part A and Part B makes it difficult for providers to innovate by providing preventive or proactive care. The cost is accrued in Part B, but the savings are in Part A (fewer hospitalizations) and are not available to fund innovations.

In addition, despite recent legislation to provide an annual composite rate update for dialysis facilities, MedPac reports consistently prove Medicare payments barely cover the cost for some dialysis providers and do not cover the costs for others. These interrelated delivery and financing deficiencies have a compounding effect on the well-known access and quality challenges faced by underserved ethnic/racial groups and geographic areas.

We need creative thinking to bring the care of kidney patients into the 21st century, the kind of “disruptive technology” thinking that led to true transformations in fields like computers and communications.

One such approach to truly transformative care that is showing considerable promise is provider implementation of structured care coordination, which is now being applied to a variety of chronic illnesses. A number of organizations is testing this approach in various programs, such as the American College of Physicians’ Patient-Centered Medical Home (, TransforMed (, which is an initiative of the American Academy of Family Physicians, and integrated care management demonstrations developed by DaVita and Fresenius Medical Care.

These approaches to evidence-based, patient-centered care for the most vulnerable patients offer great promise to improve clinical outcomes while upholding the public trust to provide true value in health care. They should serve as a model as system-wide healthcare reform is developed for this and the next generation.

A member of the Renal & Urology News Editorial Advisory Board, Dr. Nissenson is professor of medicine and director of the dialysis program at the David Geffen School of Medicine at the University of California in Los Angeles. He also is the chief medical officer for DaVita Inc.