11/22/2013 06:28 pm ET Updated Jan 25, 2014

Potential Medicare Cuts Impact Patients With Kidney Disease

The Centers for Medicare & Medicaid Services (CMS) are proposing cuts that will have a devastating impact on low income American families. If you or someone in your family has been diagnosed with Chronic Kidney Disease (CKD) or End Stage Renal Disease (ESRD), you better keep reading.

Something to consider: Even if you or a loved one has not been diagnosed with CKD or ESRD, you may still be at risk if you have been diagnosed with obesity, diabetes or hypertension, the three major causes of kidney disease.   Every year, the federal government pays approximately $33 billion to care for people with CKD and a whopping $44 billion dollars for patients needing dialysis. That is $77 billion compared to $7.5 billion allocated for HIV/AIDS medical care and prevention. Kidney disease is the eighth leading cause of death in America and according to the CDC and NIH affects approximately 26 million Americans.   In the county of San Diego, over two-thirds of the patients receiving life-saving hemo or peritoneal dialysis are Latino Americans the remainder are social-economically challenged Americans.   To gain a better understanding on what the proposed 2014 rule on (ESRD) Prospective Payment System (PPS), I asked Shaun Edelstein, Chief Operating Officer of Balboa Nephrology Medical Group in San Diego how these cuts will impact physicians and patients. In an interview Edelstein had this to say

Make no mistake about it: This potentially devastating cut will force the closure of some dialysis units in San Diego and across the nation. They just can't run at a fiscal loss given the very tight margins some of these units operate at today. Understand, if even a few of these dialysis units close, we have basically no excess capacity or space for these critically ill patients to go as most of the +/- 35 dialysis units in San Diego are at or over capacity already. You can't send these patients to the hospitals, as none of these facilities provide long-term dialysis care for patients with ESRD. Also, the cost is exponentially higher in an in-patient setting vs. outpatient dialysis centers. And this whole debacle is about cost right? So absolutely no option to kick the proverbial 'cost' to somebody else. This is exactly what we're trying desperately to prevent. This is a huge predicament especially for large groups who have the responsibility for providing life-saving care to thousands of patients every month.

He added:

You know an outsider might say, 'Well, build more dialysis units.' The regulations, both federal and state, the taxes, documentation, cost, legalities and time to certification (which alone takes about a year) are so egregious and so cost-prohibitive that nobody wants to or can afford to build anything new. So we are in a catch-22 merry-go-round... and who suffers? The patients. Especially those on the lower socio-economic ladder who cannot travel a long distance for care. Aren't these exactly the people we're supposed to be helping? We MUST break this cycle, but we can't do it alone. Promises made by the ACA and CMS to protect and offer healthcare to those in need cannot be broken... or we will face a healthcare crisis right here in San Diego.

******** When a person's kidneys are no longer able to filter the blood and process waste, they have very few choices. One, the patient can try and get on a transplant list for a donor kidney. Two, they can get dialysis at home or in most cases go to a treatment center three to four times per week. The third option for the patient is to become toxic and die.   In North America the two largest providers of clinical dialysis are DaVita and Fresenius Medical Care. In an interview with DaVita company spokesperson Skip Thurman, I asked how the proposed CMS cuts would impact patients.   Thurman stated:

The Centers for Medicare and Medicaid Services has proposed a cut of nearly 10 percent of its payment for dialysis treatment -- a payment that already fails to cover the cost of treatments. If this proposal is implemented, it quite simply puts all dialysis clinics at risk, regardless of provider. At greatest risk are centers with a high proportion of Medicare patients.

************   In an interview with Robert Sepucha, spokesman for Fresenius Medical Care, I asked him if Medicare is reversing their policy for ESRD.   He noted that,

Forty years ago, the federal government made a commitment to Americans suffering from ESRD. Whether a person is five or 65, Medicare will cover them to ensure that they receive the dialysis treatment they need to stay alive. Today, however, that commitment is in jeopardy. The proposed cuts mean that the federal government will no longer cover the basic cost of dialysis. We can and must do better.

Back in Southern California, physicians, patients and patient advocates have been meeting with members of congress urging them to contact CMS in opposition to the proposed cuts. This is in addition to a letter signed by 204 members of congress sent to HHS Administrator Marilyn Tavenner expressing their concerns. Representative Susan Davis D-California had this to say after meeting with Dr. John Videen on the proposed dialysis cuts:

Cuts such as this demonstrate the devastating effect the sequester is having on millions of Americans that benefit from various federal programs. I strongly oppose the sequester. The House needs to conference on the budget so we can end the sequester and save us from this man-made disaster.

******   Congressman Scott Peters D-San Diego has heard from constituents and met with patients and doctors -- about this issue in both Washington, D.C., and his district office in San Diego. He also made a point of visiting facilities in the district that offer dialysis services and technologies.   Representative Peters released this statement specific to the proposed cuts:

These cuts are further proof that Congress needs to get to work on the pressing fiscal issues that our country faces so that we can adequately fund the necessary investments to keep our workforce healthy and competitive into the next century while also making targeted cuts that rid the government of wasteful spending. A government shutdown and sequester undercut that goal. Hopefully in the coming negotiations over the budget, Congress can find a way to make sure that Americans who count on these vital services are not left in the cold.

**** Many Americans believe that Republicans and Democrats are divided when it comes to all health care related issues. I had the opportunity to interview Congressmen Duncan D. Hunter R-San Diego. He and his staff have been actively meeting with concerned doctors, constituents and patients.

I opposed the sequester in part because it provides no flexibility to administer budget reductions. There has got to be some adaptability and common sense that drives post-sequester budgets but it seems like too many disruptions are being forced where they might not need to happen. The sequester needs to be resolved one way or another. Either funding is restored through smarter, offsetting reductions or the right flexibility is provided. But regardless, funding for CMS in this area is something that Congress must definitely look at more closely should CMS choose to proceed.

********   For over a decade Dr. John Videen M.D. a nephrologist practicing in San Diego, has been an advocate for patients with kidney disease. He has been meeting with congressional representative regarding the the proposed cuts. In an interview Videen has this to say:

This cut makes no sense in the grand scheme of health care expenses. Outpatient dialysis services have been cut over the years as budgets have tightened, even though it is generally agreed that moving services out of the hospital will save money. Our group, Balboa Nephrology in San Diego, demonstrated health care savings in a pilot project by diverting ESRD patients with acute congestive heart failure from the emergency room to the outpatient dialysis units using a network of open clinic times and a novel transportation system. So when our patients wake up unable to breath they could have an option of calling a taxi to go to an urgent three-hour dialysis appointment instead of 911 and three days in the hospital. Cutting outpatient dialysis reimbursement gives clinics less flexibility to accommodate such a program and will continue to stress the hospital based delivery system. 

There is a saying by not taking action, you have taken action, America must wake up to the reality that we are going to lose access to medical care and treatment that we take for granted today. I guarantee you that we must be diligent and observant when cuts or access to care are proposed. In my opinion these proposed cuts are monstrous, ethically wrong and go against basic human needs.

One of the most basic rights we as Americans have is our voice to be heard, whether we are opposed or advocating to changes in public policy. No matter where you are in America you should email or phone your elected representatives to the House of Representatives and U.S. Senate. Tell them cuts to CDK and  ESRD  are unacceptable.  Request their office, send you a confirmation letter, documenting your concern regarding the issues or assistance you require. By law, a federal agency must respond to the government representative in writing within 30 days.

For more information on the proposed cuts visit here. To contact your elected representatives go to and