Advanced Plan for Health Logo
  • Mar 5, 2019

In observance of National Kidney Month, this month’s health highlight is on Chronic Kidney Disease (CKD) and Dialysis awareness and prevention.

Kidney failure and life-saving dialysis are both a catastrophic health plan expense and life-changing experience that impact health payors and lives alike. We are seeing an incidence of chronic kidney / renal disease of about 2 to 2.5 per 1,000 members.

Our very own Dr. Barbara Rutkowski, VP of clinical operations, has focused quite a bit of time and energy in helping our clients improve kidney disease outcomes and management, and is always on the lookout for new developments in this area.

“Our goal is to avoid the $350,000 to $700,000 per member per year that an employer will pay when somebody’s on dialysis,” says Rutkowski in Employee Benefit News.

As Dr. Rutkowski detailed in a past APH Blog, “Cost of Dialysis and TPA and Medical Management Best Practices,” once dialysis starts, the employer or Plan will pay these costs for 33 months after outpatient dialysis is initiated. After that time period, Medicare takes over if the individual member has made a timely application.

More detail and cautionary notes on this topic for employers are included in the APH article, “Pre-Emptive and Analytics-Based Early Action Can Delay Kidney Dialysis, Reduce Plan Costs and Improve Quality of Life," featured in the March 2019 edition of The Self-Insurer Magazine (pg. 32). The article forewarns that “the failure to monitor a dialysis patient to be sure they have enrolled successfully and timely in Medicare means that the employer keeps paying for dialysis instead of Medicare becoming the primary payor. Medicare will not send a reminder, and Medicare will not reimburse these extra health plan payments for the member on dialysis.”

As a first step in proactivity, finding at-risk individuals early is critical, since CKD does not have any discernible symptoms until kidney disease is advanced. By the time symptoms appear there is often permanent and severe kidney damage. Those with diabetes, hypertension, a family history of kidney disease or heart disease are at higher risk of developing and should be tested for CKD.

Identifying individuals who are battling these diseases or comorbidities is a critical first step in controlling CKD risk factors, modifying lifestyle and nutritional patterns of these individuals, and closely monitoring disease progression for targeted intervention.

Proactive employers looking to avoid exorbitant and potentially avoidable CKD costs will be prudent to employ advanced and predictive analytics that combine medical and pharmacy claims as well as labs, biometrics and more for current state and predictive visibility. This level of insight, as provided by our Poindexter system, can greatly assist in finding persons with metabolic syndrome, diabetes, heart disease and kidney disease – allowing employers to address predicted risks, identify and monitor patients on kidney dialysis and close care gaps to improve financial and clinical outcomes.

In a recent APH article in Workforce®, another development important to those facing CKD was covered: The article, titled “Organ Transplant Innovations Can Save Health Care Dollars” shares details about transplants with organs from hepatitis C infected donors that are saving people’s lives — and saving money for both patients and plan sponsors.

APH has the tools and resources in place to make a significant difference for those facing chronic conditions and co-morbidities. Be it through spreading awareness, providing actionable insight through our advanced and predictive analytics platform – Poindexter – or through consultative services and / or nurse navigator care management, APH is here to help you at every step of the way.

Another APH team member who is passionate about ensuring that members with chronic kidney disease have the medical management and support they need is Joy McGee-Cory, Sr. VP at APH. She has assisted many clients in successfully navigating Medicare requirements for dialysis and in obtaining favorable provider and facility contracts. From years of experience, she has written this very valued Best Practice Guide for those facing high kidney disease and dialysis costs and risks: Click here to receive your own copy of the Kidney Disease & Dialysis Best Practice Guide.