Chronic Kidney Disease: Manage Now or Pay Later

Those of us that have been around awhile have heard the following statement as long as we can remember: “An ounce of prevention is worth a pound of cure.” Often we heard it right before we were asked to do something by an authority figure trying to convince us “it was for our own good.”

In this article I will be a voice of reason providing you with a glimpse of the future if the rising cost of treating chronic kidney disease goes ignored. It provides suggestions on how to make immediate changes that are minor in scope but significantly impactful on your bottom line. It is a call to action to get started now and choose the ounce over the pound.

For the uninitiated reader chronic kidney disease (CKD), also known as chronic renal disease, is the progressive loss of kidney function. The key word here is “progressive.” Since the primary function of the kidneys is to act as a filtration and waste removal system for the body, a decrease in function means a buildup of waste products in the body and subsequent reduction in significant measures of health and wellness.

While the human body can take a lot of abuse for what seems like an indefinite amount of time, it loses its ability to adapt at some point. Kidney failure is divided into five stages based on the amount of filtration loss. If the progression of CKD isn’t halted, the kidneys eventually fail completely requiring the member to be placed on dialysis.

The symptoms of CKD and its subsequent costs increase as a member moves from one stage to the next. The severity of these symptoms has to do with the current stage of illness the member is in as well as a number of other health conditions they might have at the same time such as diabetes, heart disease, and obesity.

Because CKD is the result of conditions such as diabetes, heart disease, and obesity and not the cause of them, it is not uncommon for members with CKD to have all of them at the same time. It is well known that while CKD does not cause the named conditions it has a multiplier effect on them. This is supported by Medicare’s 2009 United States Renal Data Systems (USRDS) Annual Data Report, which clearly states, “The high level of interaction between CKD and other major chronic diseases — its “multiplier” effect — is in part illustrated by its costs.”

Symptoms of CKD become noticeable once a member has reached a 50 percent decrease in overall function. At this point the body has lost a significant portion of its ability to adapt and damage to the kidney is permanent. Still, measures can be taken to halt further disease progression.

While I can’t speak to the cultures of other developed nations, the current upward trend in the primary causes of CKD, namely diabetes, heart disease, and obesity, demonstrates that as a country we have not yet grasped the concept of “prevention.” We continue to choose video games over exercise, donuts over fruits and vegetables, and in the end whether we realize it or not, dialysis over health.

The unfortunate news is that without interventions on the part of the health plan most of your members won’t even know there is a problem until it is too late. To make things worse, even when members become aware of their condition, without encouragement and support through programs like disease and case management, many won’t make the necessary lifestyle changes to avoid the oncoming train.

Like many things in life, the lack of immediate and obvious consequences provide little motivation for health plans and their members to take steps to reduce risk and engage in preventative behaviors.

So what’s the solution? One effective measure is to engage your membership as early as possible. This can be accomplished through performing a Health Risk Assessment (HRA) that includes information that helps identify at-risk members. Remember the adage, “If you can’t find them, you can’t help them.” The HRA should be done at hire and annually and contain specific information unique to CKD. Members identified as “at-risk” should be referred to a disease or case manager and provided with educational material. The disease or case manager should provide a list of questions and actionable items to the member to be discussed with their physician.

It is imperative that the member’s primary care physician (PCP) be engaged in the process as a partner with the health plan. The best-case scenario would be that the member be in the care of a nephrologist. The nephrologist specializes in the detection, monitoring, and treatment of CKD. Current literature indicates that many members don’t see a nephrologist even up to a year prior to complete kidney failure and becoming dependent on dialysis.

Because CKD can go undetected for such a long period of time, the PCP by default will most often be the care provider involved with the patient at time of detection. While PCPs are aware of CKD and have some knowledge of treatment protocols, literature indicates that they still require additional support in treating the member and determining when it is appropriate to refer them on to the nephrologist. This can be facilitated via a disease or case management program as well as various physician tools that are available online via the National Kidney Foundation at www.kidney.org.

Studies demonstrate that timely referral by the PCP to a nephrologist is highly significant. Members seen by a nephrologist up to a year before going on dialysis have fewer complications than those who do not; and, fewer complications most often translate into lower costs.

A cursory assessment of the current programs available for the management of CKD finds there is a lot of information on how to detect and intervene at the very early stages before damage is done and costs start to mount. There is a lot of excellent research being done by the National Kidney Foundation and others to improve awareness. If one digs a little deeper, one will find that despite an increased level of awareness very few programs are targeting the earliest stages.

Instead, most programs target just CKD stages four and five. There are a number of reasons for this. One of the main reasons is the following perception on the part of health plans: Why spend money on detection and intervention for members in the early stages of CKD when I may not have them by the time they become expensive? The truth is, members with early stage CKD cost more than the average members without CKD because CKD can go undetected and therefore unmanaged until permanent damage has already been done. It is almost impossible to predict when a member will move from the moderate into the high cost category. The new healthcare reform law makes this and many similar arguments moot with its focus on early detection, preventative medicine, and the removal of lifetime benefit maximums and pre-existing conditions.

The reality of the situation is that not all health plans will have the size or resources to put large health and wellness programs in place to promote healthy lifestyles among its members and prevent CKD altogether. However, virtually all health plans should and can put programs together which provide a means of early identification, education, support via disease or case management, and coordination of care via the PCP and nephrologist. These simple but effective and inexpensive interventions can make a substantial impact on the health plan’s bottom line and the quality of life for its members.

Resources

National Kidney Foundation – www.kidney.org

Medical Information Institute – www.meiresearch.org

United States Renal Data System – www.usrds.org

National Institute of Diabetes and Digestive and Kidney Disease – www2.niddk.nih.gov

Healthy People Report 2010 – http://www2.niddk.nih.gov/AboutNIDDK/Organization/Divisions/KUH/KUHKidneyHP2010.htm