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Emergency Dialysis: A Crutch for Fee-For-Service Healthcare

Physicians often diagnose patients with chronic kidney disease (CKD) too late in the process, when dialysis is the only option left. This isn’t negligence on the part of physicians — it’s simply a consequence of a fee-for-service (FFS) healthcare model that works against patients’ financial well-being and deemphasizes preventative care.

Of the roughly 780,000 Americans who live with end-stage kidney disease, 71% are on some form of dialysis.

Dialysis can provide an effective life-sustaining treatment for many with kidney failure, but it is not the best option for most. First, there’s the commute to a nephrology clinic or dialysis center, which for patients in rural communities and communities of color can take hours. Once they arrive at the facility, patients undergo four-to-five hour-long treatments that leave them with mild to severe fatigue. This routine puts tremendous strain on patients and prevents them from fully participating in the workforce and contributing to their communities.

Given the toll that dialysis can take on patients, you might think that providers would do everything they can to avoid dialysis. Unfortunately, that’s not always the case.

Physicians often diagnose patients with chronic kidney disease (CKD) too late in the process, when dialysis is the only option left. This isn’t negligence on the part of physicians — it’s simply a consequence of a fee-for-service (FFS) healthcare model that works against patients’ financial well-being and deemphasizes preventative care.

To catch CKD before dialysis is needed, our healthcare system must shift toward a more value-based approach that accounts for social determinants of health (SDOH) and prioritizes patient outcomes above all else.

FFS care and chronic disease don’t fit together

Every patient walks into a healthcare facility with their own unique family history, upbringing, and financial situation. Providers need to consider these factors to provide the best care possible.

As you probably know, in an FFS model providers are paid based on the number and complexity of treatments they administer. The problem with this model is that it doesn’t incentivize the quality of patient outcomes — meaning preventative care isn’t always the focus and factors like a patient’s SDOH often go unconsidered.

When it comes to chronic diseases like CKD, factors like economic insecurity, family history of disease, and access to healthcare facilities all contribute to a patient’s risk level. So neglecting to account for them only increases the likelihood of potential warning signs slipping through the cracks.

However, a value-based care model compensates providers based on the quality of health outcomes. Since SDOH play a major role in health outcomes, physicians are more likely to factor them into treatment and rehabilitation. With a more holistic view of the patient’s risk level, the physician can recommend preventative care measures — like CKD testing — earlier in the process.

With nearly 60% of adult Americans living with a chronic disease, we can no longer afford to treat these patients in a vacuum. A shift to a value-based care model would prioritize routine, preventative care and keep emergency treatments like dialysis reserved for emergencies.

How do we transition to a value-based care model?

Transitioning to a value-based care model is no simple task. It requires a combined effort from providers, payers, patients, medical schools, and both the private and public sector. Right out of the gate, physicians, nurses, and care teams have to relearn the way they think about care. They must view each patient in the context of broader population health, and consider the external factors that have shaped them. This shift has to start in education — schools must make space in their curricula to discuss value-based care.

A shift to a value-based care approach also means rethinking the business of medicine. Providers need to have the infrastructure in place to track and glean insights from a more complex set of clinical data. Hospital systems and larger providers are well-suited to make this change, but small practices may not have the financial bandwidth. This is where public policy comes in.

Public policy can give providers the resources, directions, and timely mandate needed to transition from FFS to a value-based model. We’ve already seen hints of the impact public policy can have through the recent passage of the No Surprises Act, which protects patients from surprise medical bills and — for the first time — obliges physicians to consider cost when recommending care.

More research and outreach efforts around the effectiveness of value-based care is necessary to spur public support for additional legislation. The Centers for Medicare and Medicaid Services (CMS) has already begun these efforts by piloting several value-based trial programs with hospitals and providers, including one for renal dialysis facilities. Positive returns from these experiments will be a valuable first step toward making the transition to value-based care feasible for medical providers of all sizes.

Lastly, the transition will require a shift in perspective for patients. Most patients don’t think about healthcare until they’re already sick — a natural byproduct of a system that deemphasizes preventative care. Our current model also discourages patients from advocating for themselves: It’s easier for a patient who’s just started to show CKD symptoms to explore their options than it is for a patient who has just been diagnosed with end-stage kidney failure. In a value-based care model, patients are encouraged to take a greater role in managing their health, which research has shown improves overall health outcomes.

Value-based care and the road ahead

Value-based care is by no means a perfect solution. There are very real questions about how to tie payments to outcomes and whether the model encroaches on patient privacy.

However, the model is clearly superior to FFS in the way it reflects the realities of today’s patients, many of whom struggle to cope with chronic diseases and feel unsupported by our current healthcare system. Ultimately, a value-based approach would catch CKD earlier, reduce reliance on dialysis, and empower patients to reclaim control over their treatment — and their lives.

Photo:, Getty Images

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Amit Kapoor

Dr. Amit Kapoor is a Chief Nephrologist at Strive Health, a national leader in value-based kidney care, which serves patients with chronic kidney disease.

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