In a recent article in AJKD, Dr. Robert Rubin provides an insider’s perspective on health care policy in general and ESRD policy in particular in the United States. From 1981-1984, Dr. Rubin notably held the positions of Assistant Surgeon General and Assistant Secretary for Planning and Evaluation at the US Department of Health and Human Services. He has remained active in health policy since.
Based on his personal experience, Dr. Rubin describes the development of the first dialysis bundle in the early 1980s, which was an attempt to control costs while promoting quality care. In this effort and very relevant to today’s expanded bundle, he notes that there are 4 major principles that drove and continue to drive health care policy: (1) fixed or reduced costs, (2) ensured outcomes (or no evidence of undertreatment), (3) streamlined administration, and (4) political viability. In addition, similar to the current ESRD bundle, Accountable Care Organizatons (ACOs) and ESRD Seamless Care Organizations (ESCOs), an incentive was offered: if providers could provide quality care at a cost below what CMS paid them, they could keep the difference. Regardless, of political affiliations, these principles have been supported and used by all subsequent US administrations.
The original bundle was very successful, the bundled payment essentially remaining unchanged for ~30 years, despite inflation; however, innovations occurred, particularly with medications, and these cost a lot of money. Recognizing this, Congress directed the secretary of HHS to explore an expanded bundle that would include, among other things, these costly medications. Dr. Rubin was a co-chair of the committee investigating an expanded bundle from 2005-2008, helping to promote a system that would meet the 4 major principles described above. This was not without controversy, and further cost-containing measures were also mandated by Congress, but, to date, the initial years of the expanded bundle have been fairly successful.
Per Dr. Rubin, substantial challenges remain. These include the expanded bundle still remaining relatively limited, addressing only Medicare Part B costs; dialysis-specific ACOs, called ESCOs, are being piloted to explore whether a broader bundle can be successful. Additionally, bundled systems leave little room for implementing expensive innovations in health care, particularly those that are associated with a benefit several years down the road; how CMS will design systems to account for new treatments is an important unanswered question. Finally, Dr. Rubin notes concerns with the current state of affairs in Washington, stating that “the spirit of working together to solve our nation’s problems appears to be missing in action.” He eloquently describes his experience on the inside and how negotiations and compromise occurred without the public vitriol that seems to be pervasive today. In fact, per his report, bipartisan compromise and personal relationships among lawmakers were the critical elements in passing the 1983 prospective payment system, which laid the groundwork for dialysis care for the next 30 years and beyond.
Finally, Dr. Rubin asks us, as members of the nephrology community, to consider how Washington views us – and it is likely far more homogenously than we see ourselves. They see the most expensive portion of the most expensive part of government, Medicare, and a dialysis industry where 2 large companies are quite profitable. They see prior success in cost containment, and potentially view dialysis as low hanging fruit when it comes to budget cuts. They see reasonable well compensated medical specialists. Clearly this is a generalization, but there is also truth in these impressions. Given these, Dr. Rubin ends by reminding us, as kidney disease professionals, that all of us need to let Washington know what truly matters to us and promote our field as one that does tremendous good. A key part of (re)energizing nephrology includes understanding and shaping the policies that allow us to do the best for our patients and demonstrate to the next generation of doctors that nephrology is a field where you can make a difference.
Daniel E. Weiner, MD, MS
AJKD Deputy Editor