Providing More Holistic CKD Care
March is National Kidney Month. Much has been written to increase awareness of risk factors for kidney disease to avoid or delay kidney failure. Since reducing or eliminating kidney failure is a goal of the kidney community, why don’t we provide services in physician’s offices that can improve nutritional, physical functioning, emotional well-being, and rehabilitation— instead of waiting until patients’ kidneys fail and they become malnourished, depressed, and unemployed?
The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) established Medicare coverage for six sessions in a lifetime of Kidney Disease Education (KDE) for those with Medicare who have Part B and a diagnosis of Stage 4 CKD1. To be reimbursed:
- Patients must be referred by the physician treating the patient’s CKD
- KDE must address certain topics
- KDI can only be provided by “qualified providers” (physician, physician’s assistant, nurse practitioner or clinical nurse specialist, and certain institutional providers).
CMS assigned the G-codes G0420 for one-on-one sessions and G0421 for sessions with 2-20 participants, not all of whom have to have Stage 4 CKD (G0421).2 The KDE benefit is subject to the Medicare Part B deductible and 20% coinsurance that may be paid by other coverage.
Offering this service could help so many more who have CKD 4, but it has only been used by a small number of Medicare beneficiaries. Could the small numbers of patients using the kidney education benefit be related to patient factors? Or, could the narrow definition of who qualifies to provide and to receive the education, no requirement to measure outcomes, payment amount, or could something else be contributing? More research is needed to determine why.
Some companies and organizations provide free CKD education to people with any stage of kidney disease, including but not limited to:
- Kidney School (Medical Education Institute’s free tailored, online program)
- How to Have a Good Future with Kidney Disease (Medical Education Institute’s free online video CKD classes. Teaching slides are also free, here.)
- Kidney Smart (DaVita’s in-person program)
- Treatment Options Program (TOPS) (Fresenius’ in-person program)
- Reach Kidney Care (Dialysis Clinic, Inc.’s in-person program)
- Patient Education Program (Missouri Kidney Program’s in-person program)
CKD education is associated with better outcomes. Studies have shown that those who receive CKD education have higher knowledge scores, are more interested in choosing a home treatment especially PD,3 have slower CKD progression4, increased fistula placement and use, and are hospitalized less.5 Referral for CKD education can help patients learn what they need to know about managing their kidney disease and choosing a treatment option.
Medicare pays for a number of other preventive services that could help people with CKD as well, including but not limited to:
- Diabetes screening and self-management education
- Medical nutrition therapy
- Medication therapy management
- Obesity screening and counseling
- Tobacco use cessation counseling
- Alcohol misuse screening and counseling
- Cardiovascular disease screening
Encouraging CKD patients to use these benefits could reduce the number of those requiring dialysis or transplantation.
However, it takes an interdisciplinary staff to better address some problems. For example, physicians, physician assistants, and nurses may not:
- Have the broad knowledge that pharmacists do of options for medications to use to treat different conditions, their contraindications, side effects, food/drug interactions, and cost comparisons.6
- Know as much as experienced renal dietitians on ways to meet CKD patient’s nutritional needs when patients are living with multiple diagnoses.
- Know as much as experienced renal social workers about screening and addressing depression and other mental health and lifestyle behaviors, financial barriers, and work-related concerns.
Is it time to look at expanding busy nephrologists’ practices to include other disciplines who have expertise that could help people with CKD? Providing more services in a one-stop nephrologist’s office may allow nephrologists, PAs, and nurses to address patients’ medical needs, and may offer those with CKD the chance to live longer, happier, and more productive lives with a treatment that fits better with those things they value—in their homes, workplaces, and communities.
- Medicare & Kidney Disease Education↩
- Medicare Claims Processing Manual, Chapter 32 Special Services↩
- King K, Witten B, Brown JM, Whitlock RW, Waterman AD. (2008). The Missouri Kidney Program's Patient Education Program: a 12-year retrospective analysis. Nephrol News Issues 22(12):44-5, 48-52, 54.↩
- Enworom CD, Tabi M. (2005). Evaluation of Kidney Disease Education on Clinical Outcomes and Knowledge of Self-Management Behaviors of Patients with Chronic Kidney Disease. Nephrol Nurs J. 42(4):363-72.↩
- Dixon J, Borden P, Kaneko TM, Schoolwerth AC. (2011). Multidisciplinary CKD care enhances outcomes at dialysis initiation. Nephrol Nurs J. 38(2):165-71.↩
- Medicare Learning Network, Centers for Medicare & Medicaid Services Preventive Services↩