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On June 29^th, 2015, the Trade Adjustment Assistance/Trans-Pacific Partnership bill was signed into law by President Obama.  So, what do practicing nephrologists need to know about the 59 page “trade bill”? A lot!

Although section 601 on page 27 offers a fascinating and detailed definition of recreational performance outerwear for the purposes of tariffs, it is section 808 – the last two pages of the bill – that is of key relevance to nephrologists and their patients. Once implemented on January 1^st, 2017, this new law will reverse the current Medicare regulations prohibiting payment to ESRD facilities for acute dialysis.

This law is good news for nephrologists and our patients. The inability to place AKI patients requiring dialysis in ESRD facilities began with a clarification ruling from the Centers for Medicare and Medicaid Services (CMS) on July 18, 2012. Since then, physicians have struggled to place patients with AKI in need of outpatient dialysis. The loss of the ESRD facility option resulted in prolonged hospital stays, great inconvenience for patients who have had to travel long distances to return to an acute unit, and pressure to prematurely declare patients as ESRD. The return of the ESRD facility option for patients with AKI is reasonable, and should be a benefit to patients.

It is critical, however, that patients, staff, nephrologists, and CMS understand that the care of patients with AKI requiring dialysis is vastly different from the care of patients with ESRD requiring dialysis. In contrast to the protocol-driven world of ESRD care, patients with AKI require more individualized care, with a focus on measures to promote recovery of kidney function. Such measures include careful adjustment of dialysis prescription to avoid hypotension, frequent measurement of labs and monitoring of urine output, and avoidance of nephrotoxic medications. ESRD facilities should have explicit policies and procedures to identify and care for AKI patients. Excellent AKI care can occur in an ESRD facility; however, planning and implementing AKI-focused care that emphasizes kidney function recovery is required.

The passage of the trade bill represents a major step forward in the care of Medicare patients with AKI requiring dialysis.  Many questions remain, including details of implementation and reimbursements.  What is clear, however, is that nephrologists and ESRD facilities need to begin preparing.  With appropriate anticipation and readiness, we have the potential to significantly improve the care of this at-risk population.

Michael Heung, MD, MS
Clinical Associate Professor of Medicine
University of Michigan, Department of Internal Medicine
Medical Director, Acute Dialysis Program
University of Michigan Health System
Ann Arbor, MI

Sarah Faubel, MD
Professor of Medicine
University of Colorado Denver and
Denver VA Medical Center
Internal Medicine, Renal