By Reed Abelson and Katie Thomas, New York Times
President Trump issued a sweeping set of proposals aimed at improving medical care for the tens of millions of Americans who have kidney disease, a long-overlooked condition that kills more people than breast cancer.
“This is a first, second and third step. It’s more than just a first step,” Mr. Trump said in a speech Wednesday, which was attended by patients, advocates and industry executives.
Mr. Trump signed an executive order directing federal agencies to educate and treat people with early forms of kidney disease, to make kidney transplants easier to get, and to shift the financial incentives for clinics and doctors away from the existing system that relies heavily on dialysis.
“The result will be more and faster transplants for those in need,” said Mr. Trump, who also said his administration would work to encourage the development of new treatments like artificial kidneys.
“For 50 years, we have had basically a stagnant system of how we treat people with chronic kidney disease,” Alex M. Azar II, the health and human services secretary, said in a briefing held Wednesday morning. Mr. Azar has made kidney disease one of his priorities because his father needed dialysis for several years and later received a kidney transplant.
Mr. Trump did not mention his wife’s kidney surgery last year, and at the press briefing, White House officials did not answer a reporter’s question about whether Melania Trump was involved in these efforts.
The president set an ambitious goal to remake how Americans with kidney disease get treated, by aggressively seeking to lower the costs by encouraging in-home dialysis and organ donation. Both options are seen as better treatment for patients than clinic-based dialysis. However, transforming the area may prove daunting, and many of previous efforts have fallen short.
About 37 million adults have chronic kidney disease, or about 15 percent of American adults. Medicare, the federal health insurance program, covers about half a million people with end-stage kidney disease and spends disproportionately on their care. Although they are just 1 percent of Medicare beneficiaries, they account for 7 percent of the program’s medical claims, some $35 billion. The total cost to Medicare for kidney care each year exceeds $100 billion.
Medicare has covered people who need dialysis since 1973, when the federal government took the unheard-of step of covering people with a single condition — end-stage renal disease — because they would not otherwise be able to afford care. Patients who need dialysis are hooked up to a machine that filters toxins from their blood three times a week, an onerous process that disrupts people’s lives and takes a heavy toll on their health. Half of the people who are on dialysis die within five years, according to federal officials.
In sharp contrast to treatments in areas like cancer or H.I.V., the main treatment for people with end-stage kidney disease — dialysis — has not changed much over the years.
“Dialysis has been a wonderful technology, but it has suffered from little innovation,” said Dr. John Sedor, a kidney specialist at the Cleveland Clinic who works with federal officials in a program to foster new developments. “It’s a government-run program that has discouraged private investment.”
Officials said they wanted 80 percent of newly diagnosed people with end-stage kidney disease to be moved from clinic-based dialysis by the year 2025, and to reduce the number of Americans who develop end-stage disease by 25 percent before 2030. Today, only about 12 percent of Americans get dialysis at home, an amount that lags other countries.
The Trump administration wants to encourage living donors by adding reimbursements for lost wages and child care, as a way to double the number of kidneys available for transplant by 2030. Organs from living donors are considered the best option for people who need transplants, but they too require recuperative time.
“We, in the United States, have too much in-center dialysis,” Mr. Azar said. “It is mentally and physically draining on you as an individual.”
If the administration is successful, the initiative could lead to a shake-up of the dialysis industry, which is dominated by two companies, DaVita and Fresenius Medical Care. They operate about 70 percent of the country’s dialysis clinics.
In singling out kidney disease, Mr. Trump has taken on an issue widely seen as overdue for reform, and appears to be adding it to his list of health initiatives, a top priority for voters.
At the speech, Mr. Trump emphasized the administration’s work to combat the opioid epidemic, the quest to end H.I.V. and said there would soon be more news on efforts to control drug prices. He also said he would protect people with pre-existing health conditions, just one day after administration lawyers joined several states and argued before an appellate court that the Affordable Care Act should be overturned.
Some of his efforts to address health care issues have faltered. On Monday, a federal judge threw out a key component of the president’s drug-pricing plan, one that would have required pharmaceutical companies to disclose the price of their drugs in television advertisements. And Mr. Trump has largely abandoned efforts to repeal the Affordable Care Act through Congress.
His decision to focus on kidney care was met with a mix of surprise and praise.
“We are very optimistic and excited that there is great attention at the presidential level,” Tonya Saffer, the vice president for health policy at the National Kidney Foundation, a nonprofit advocacy group, said in an interview before the announcement. “It’s really been four decades since anybody has paid attention to this space in a very meaningful way.”
It’s unclear how many of the initiatives announced Wednesday were new. Many proposals have been in the works for months, or represent the evolution of programs that were already underway. In March, top Trump health officials, including Mr. Azar, outlined steps the administration was taking to improve kidney treatment, including streamlining the process for organ transplants and improving financial incentives for patients to use in-home dialysis.
In a twist, a major of aspect of their initiative would rely on an innovation center created under the Affordable Care Act, which President Trump has vehemently opposed. The proposal would create pilot programs to test alternate ways of reimbursing physicians to encourage treatment of kidney disease earlier and potentially avoid the need for dialysis.
“It is the needed paradigm shift for the United States,” Dr. Brigitte Schiller, the chief medical officer for Satellite Healthcare, a nonprofit chain of dialysis centers, said in an interview before the announcement. The current system “makes it very easy to send a patient to the centers.”
In the United States, the rates of kidney transplants and in-home dialysis has lagged those in other developed countries, a situation that many say can be blamed on a host of financial incentives that discourage better options.
Companies that operate clinics, such as DaVita and Fresenius, profit from recurring visits by patients coming to their centers. In addition, many kidney specialists, or nephrologists, have a financial interest in dialysis centers in their communities, either by serving as the clinics’ medical directors or owning a stake through a joint venture with a dialysis operator.
“One of the fundamental challenges is the fact that physicians don’t make their money treating kidney disease; they make money on dialysis,” Arvind Rajan, a co-founder and chief executive of Cricket Health, a San Francisco start-up that is focusing on kidney care, said before the announcement.
Changing the incentives “is sorely necessary,” added Mr. Rajan, who said private insurers that are paying for kidney care have already begun trying to shift more people to home or to consider transplants. “The landscape has changed really quickly,” he said.
While policy experts praised the president’s efforts, many also cautioned that significant change would not be easy. Many people with end-stage kidney disease are coping with other serious health conditions or are facing other problems, such as a lack of resources or support that may make it hard to take advantage of alternative treatments.
Although the big chains have also begun selling in-home dialysis services, they have invested heavily in their brick-and-mortar centers, Dr. Graham Abra, a specialist at Stanford University, said before the president’s speech. “There’s an incentive if you build a center to fill it, and push that,” he said.
DaVita and Fresenius said in separate statements that they welcomed the president’s attention to this area, that they were already investing in alternatives to traditional dialysis, and encouraged patients to pursue the best options for their health.