“July and August will be critical months to take our message to Washington: no more cuts for dialysis patients and their providers.”

The recent proposal from the Centers for Medicare & Medicaid Services (CMS) to cut reimbursement for dialysis treatments by 9.4 percent has made me think hard about where dialysis has been, where it is now and where it might be headed. When I began my internship and residency at Michael Reese Hospital in Chicago (now gone, unfortunately), the Medicare entitlement for dialysis had not yet been enacted. Michael Reese had a long connection with pioneers in dialysis dating back to the 1920s. During my internship I rotated on the nephrology service. We had converted a hospital room to a dialysis ward and built Kiil dialyzers each time we wanted to do hemodialysis. We created Scribner shunts for blood access, and each treatment was an exciting challenge to get through without hypotension, clotting or other misadventures. We also had more than 40 patients on intermittent peritoneal dialysis (IPD). They would be admitted to the hospital each week, have a peritoneal catheter inserted and receive 48 hours of IPD. As the intern on the service, I admitted each patient, drew blood and then ran a set of electrolytes in a dedicated lab on the ward. I prescribed the peritoneal dialysis regimen for the 48 hours based on the physical examination and laboratory values. The Medicare entitlement for dialysis was enacted in the first year of my residency, 1972, and implemented in 1973. It changed everything.

By 1977, when I moved to UCLA, thousands of patients were on regular dialysis treatment. We converted a four-bed hospital room into our outpatient dialysis unit, and used coil dialyzers with Travenol RSP (recirculating single pass) delivery machines. Because of the high compliance of the coils and the lack of ultrafiltration control, hypotension was the rule, along with other complications, such as coil rupture. Despite these challenges, we saw significant life extension and improvement in quality of life. Over the next 10 years incremental improvements in the therapy occurred and technology improved, but mortality and morbidity remained high and anemia emerged as a nearly universal, serious complication of end stage renal disease (ESRD). Frequent blood transfusions led to severe iron overload and human leukocyte antigen (HLA) sensitization, making kidney transplantation difficult. When recombinant erythropoietin (EPO) became available in 1989, the quality of the life of countless thousands of patients improved, but little progress was made in morbidity or mortality. Around this time, the importance of adequate solute removal was becoming clear, and dialysis prescriptions throughout the country were adjusted. Again, though, measurable improvements in mortality and morbidity were small.

It is becoming clear that many of the fundamental factors we have focused on for years, though necessary for improving survival and lowering hospitalization rates, are not sufficient for accomplishing these goals. More complex clinical issues need to be tackled, including fluid management, infection prevention, diabetes management and medication management. In order to design and implement such complex clinical issues, dialysis facilities will need to do more with the limited resources they have.

That brings me to the present, and the proposal to take significant amounts of money out of the ESRD program. This is in response to dialysis providers doing exactly what CMS hoped they would do when the bundled payment system was implemented—be more efficient! This enormous effort, which was undertaken while continuing to maintain excellent patient outcomes, was accompanied by multiple increases in the price of recombinant EPO, and increases to other costs of delivering high-quality services to patients. The large reimbursement cut CMS has put forth has the potential to significantly decrease patient access to care. Facilities may have to close completely or remove shifts, and providers’ ability to continue to innovate, drive complex clinical programs, decrease mortality and hospitalization rates, improve the patient experience of care and ultimately improve the lives of patients will be gone.

As physicians, we need to focus on how this proposed rule affects our patients. They deserve to receive the care they need, and if cuts are made, they will not receive that care. We need to advocate for our patients and let our voices be heard on their behalf. Contact your congressional representatives and senators, let them know what is happening and ask them to intervene—for the good of our patients. We must not let this progress be stopped.

If history teaches us anything about the care of frail, vulnerable, chronically ill patients, it is that compassionate, comprehensive, coordinated care is essential to improving their lives. We can provide such care only if we have sufficient resources to develop the necessary programs. Sadly, policy-makers have not learned this lesson, and our patients bear all the risks that result.

You can make a difference and have your voice heard in fighting this rule.  Here’s what you can do:

• Visit DaVitaAdvocacy.com to urge your congressional leaders to call CMS today. It takes less than one minute to submit your comments.
• Educate your friends and family and encourage them to reach out to their congressional leaders on this issue. On Tuesday, August 13, 2013, join myself and other representatives from the kidney care community for an important Google+ Hangout. We’ll engage in a dynamic discussion about the proposed cut and what it means for hundreds of thousands of Americans who rely on dialysis for survival.

As George Bernard Shaw said,

“We learn from history that we learn nothing from history.”