Many nephrologists and other healthcare providers (HCPs) have enthusiastically embraced the July 10 presidential executive order titled, “Advancing American Kidney Health Initiative.” The 3 main components include a reduction in the end-stage renal disease (ESRD) rate by 25% by 2030; a substantial increase in home dialysis so that 80% of new ESRD patients can receive dialysis treatment at home; and a doubling of the number of kidneys available for transplantation by 2030. The US Secretary of Health and Human Services has stated, “Ideally, we’d want to offer dialysis providers incentives to get patients off dialysis through transplants.” Some HCPs appear bewildered by the unprecedented extent of the overhaul, including the government’s plans for mandatory implementation.

The initiative includes some novel measures, such as the mandatory “ESRD Treatment Choices” (ETC) model, which empowers nephrologists to take the lead in care coordination. The goal is to adjust Medicare’s fee-for-service payments and provide financial incentives to increase rates of home dialysis and kidney transplantation. The plan calls for approximately 50% of the nation’s dialysis facilities and “managing clinicians” to be selected randomly on the basis of their “Hospital Referral Regions” (HRRs). The argument in support of the mandatory participation is that if it were voluntary, only a small sample of providers with higher rates of home dialysis or kidney transplants relative to national benchmarks would participate. Thus, out of some 300 HRRs in the nation, about 150 of them, including their dialysis clinics and affiliated nephrologists, will be randomly selected to be part of the ETC model. This is expected to be implemented as early as January 2020.

The dialysis industry is expected to align with the plans and suggested timeline. For the approximately 10,000 practicing nephrologists in the United States, this venturing into the unknown may cause some level of anxiety. Would the principles of public health and science justify this new practice pattern and mandatory randomization of doctors to expand home dialysis and kidney transplantation? If the planned inclusion of half of all nephrologists is inevitable, should those not randomly assigned into the ETC be given a chance to volunteer? What about the primary and secondary prevention of CKD, such as managing CKD risk factors and slowing disease progression rate, respectively?

These and other questions are expected to be answered throughout 2020 and beyond, but for now, the HCPs and patients that make up the kidney disease community are venturing into uncharted territory. All of us must team up to make great things come out of this unprecedented time.


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Kam Kalantar-Zadeh, MD, PhD, MPH, is professor & Chief, in the division of Nephrology & Hypertension at the UC Irvine School of Medicine in Orange, California.

Twitter/Facebook: @KamKalantar