Decrease the Increase

More ESRD Patients Could Collapse Existing System

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Public Health Feature - June 2006  

By  Erin Prather
Associate Editor

As chair of the Texas Renal Coalition (TRC) board, Glen Stanbaugh Jr., MD, spends many afternoons working to improve the health care of patients affected by kidney disease. A retired Lubbock nephrologist with more than 30 years of experience, he has witnessed the alarming growth of patients afflicted with end-stage renal disease (ESRD).  

Although the federal and state governments help those with the disease pay for their care, Dr. Stanbaugh warns the increasing number will cripple that aid and place ESRD patients in alarming predicaments.  

"The only way to treat ESRD is with dialysis or transplantation, both of which are extremely expensive. As of now, the growing number of ESRD patients is outstripping treatment resources," he said. "You can build more dialysis centers, but you can't necessarily grow more nephrologists, nurses, or kidney donors."

Nationally, the Medicare End Stage Renal Disease program provides federal funding for individuals with diabetes, hypertension, or other diseases that cause ESRD. It specifically includes coverage for kidney transplantation and is the only federal program that finances disease-specific services to a segment of the American population on a universal basis. Eligibility is based on confirmed diagnosis of the disease, regardless of the patient's age.

But Medicare can't bear the enormous costs alone. The U.S. Centers for Medicare and Medicaid Services (CMS) reports spending on hemodialysis, the most common type of treatment for ESRD patients, and associated care is now more than $65,000 per patient annually.  Pharmaceutical costs have also played a role in the rising costs of the Medicare ESRD program.

The Texas Department of State Health Services (DSHS) reports that most dialysis patients do not receive medical benefits from Medicare for three months after dialysis begins, and Medicare does not cover most drug and travel expenses associated with ESRD treatment, except immunosuppressive drugs for certain Medicare-eligible transplant patients.

According to the End Stage Renal Disease Network of Texas, more than 36,000 of the 320,000 patients who receive ESRD therapy nationally are Texans.   The Texas Legislature created the Kidney Health Care Program (KHC) in 1973 to ease the financial burden on ESRD patients. It directs the use of state funds and resources for their care and treatment. Spending for drugs used to treat ESRD patients accounted for KHC's largest expenditure in 2005, totaling $13.4 million or 68 percent. 

ESRD on the Rise

A report by the Centers for Disease Control and Prevention (CDC) confirms that the incidence of ESRD has risen progressively during the past three decades. Kidney disease is the ninth leading cause of death in the United States, and the number of new ESRD cases swelled from 14,500 in 1978 to 100,359 in 2002. At the same time, the number of Americans on dialysis and with kidney transplants skyrocketed from 42,000 to 431,000.

Alarmingly, CDC also reports that by 2030, the annual number of people with new onset of ESRD will exceed 450,000, and those receiving dialysis or who have had kidney transplants will top 2 million.

Reasons for the increase in patients include growth in the number of people diagnosed with ESRD or chronic conditions that lead to it, such as obesity and diabetes, and continued progress in treating kidney diseases, which means that more patients are living longer.

Last summer, Dr. Stanbaugh met with state health commissioner Eduardo Sanchez, MD, to propose a new project TRC was considering to reduce the increasing number of patients with ESRD.

"Both the commissioner and I understand the major problem with ESRD treatment is its growing number of patients," Dr. Stanbaugh said. "The current Medicare program can't cover what it used to for patients, and neither can the state. Simply put, there are too many [patients] for the money that's available."

TRC is developing educational materials for Texas families afflicted with ESRD and the physicians who treat them. The coalition is working with the Texas Medical Association, DSHS, and other health entities to prevent Texans from developing ESRD and hopes to develop a media campaign for the public this year.

"TRC would like a statewide media blitz emphasizing the importance of strict high blood pressure and diabetes control," said Dr. Stanbaugh. "Not controlling these diseases is known to lead to patients developing ESRD. Patients must be educated about the consequences of developing ESRD and that it's up to them to personally prevent development of the disease."  

Controlled Blood Pressure Is Vital

Daniel I. Feig, MD, chief of the Pediatric Hypertension Clinic at Texas Children's Hospital and Ben Taub General Hospital in Houston, points out that it is imperative for children with high blood pressure to get it under control. He says high blood pressure will almost always follow a child into adulthood. Although a child may not have ESRD, he or she will most likely become a hypertensive adult who can develop the disease. Of the risk factors for developing ESRD, hypertension is the one most amenable to currently available therapies, he says.

"Physicians need to measure a child's blood pressure during clinic visits," said Dr. Feig, an assistant professor of pediatrics at Baylor College of Medicine. "The earlier a physician can identify blood pressure problems, the earlier steps can be taken to deal with and prevent the further development of that condition. Getting blood pressure under control means less long-term organ damage for the patient. This is particularly true for kidneys, which cannot be repaired once they are scarred," he said.

"The adult numbers are concerning, because although many people are prescribed blood pressure medication, the treatment success for getting folks into the normal blood pressure range is well less than 50 percent. That number has to increase. Although there are guidelines, physicians need to remember that the treatment of hypertension should be individualized for each patient. I'd like to believe it is possible to get most people's blood pressure under control."

The CDC report concludes that although health care professionals know how to prevent or delay the onset of kidney disease, not enough is being done to reduce increasing patient numbers. It recommended a comprehensive public health approach to address the problem. Dr. Stanbaugh believes Texas should be a leader for such a campaign.

"TRC and its partners must educate Texans on how to prevent the development of ESRD. If something is not done, the increasing number of patients with ESRD will strain or collapse federal and state programs. Those patients will be left without resources and have only the guarantee that they will quickly succumb to the disease without treatment."

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629.  

 

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