End-stage renal disease (ESRD) consistently ranks among the top 10 catastrophic stop-loss claims for reinsurance carriers. According to the most recent Sun Life report, it ranked #10, with reimbursements totaling $54.3 million in 2022 (SunLife, 2023). The report indicates that 71% of all stop-loss claims stem from at least one of these top ten conditions, underscoring the need for robust case management across these diagnoses. Notably, ESRD is unique in that it entitles patients to Medicare coverage regardless of age. This might lead one to assume that chronic kidney disease (CKD) and ESRD would rarely impact stop-loss claims; however, 75% of a dialysis facility’s clientele is Medicare beneficiaries.
Given this context, it is worth examining how a disease process that theoretically bills managed care only 25% of the time frequently appears on the “high dollar report.” The prevailing perception among providers is that Medicare reimbursement rates are low, often resulting in financial losses (Dialysis PPO, 2016). When facilities experience losses on 75% of their cases, they must generate higher margins on the remaining 25% to ensure profitability. This is often achieved through favorable contracts with managed care organizations that secure steady revenue streams. Patients with ESRD who are on hemodialysis typically require treatment three times a week, resulting in a high volume of services. Additionally, facilities often include high-cost services such as medication management and nutritional counseling to bolster revenue.
It is critical for nurse case managers assisting renal patients to understand ESRD Medicare. ESRD Medicare is specifically designed for patients requiring dialysis or kidney transplants, with eligibility commencing after three months of dialysis treatments or upon receiving a kidney transplant. For patients with managed care insurance, this serves as their primary coverage until transitioning to Medicare after 30 months on dialysis. During this period, payers are committed to high-cost treatments, as they work to convert members to Medicare. Average monthly costs for ESRD can range from $67,000 to $85,000 (Dialysis PPO, 2016).
Given these high costs associated with CKD and ESRD, how can a case manager control expenses while ensuring high-quality outcomes? Approximately 80% of ESRD cases are attributed to either diabetes or hypertension (Koye et al., 2018). The first line of defense is prevention and early detection. The ultimate goal is to prevent a CKD diagnosis from progressing to ESRD. Typically, patients do not present symptoms of CKD until they have advanced disease; often, CKD is diagnosed through routine screenings. Type 1 diabetics should have yearly screenings starting five years after diagnosis, while Type 2 diabetics should begin annual screenings at diagnosis (American Diabetes Association & KDIGO, 2022). Screening involves a spot serum glomerular filtration rate (eGFR) and a spot urine albumin-to-creatinine ratio (ACR). Any ACR >30 or eGFR <60 should prompt a referral to a nephrologist (de Boer et al., 2022). Research shows that less than 50% of patients are screened for albuminuria annually (Barzilay et al., 2024). Identifying diabetic patients early can significantly reduce costs and improve outcomes. Annual health screenings are vital components of preventative healthcare, and nurse case managers play a key role in ensuring patients receive them.
Once a patient is diagnosed with ESRD, a transplant becomes the only “cure.” Educating patients about the transplant process and eligibility criteria is essential. A considerable portion of a nurse case manager’s time will be spent facilitating referrals to transplant centers and coordinating evaluations. In the U.S., the United Network for Organ Sharing (UNOS) manages the transplant waitlist. Currently, there are approximately 106,000 individuals on the national transplant list, with 92,000 (87%) awaiting kidney transplants, and the average wait time is three to five years (National Kidney Foundation, 2024). Positive patient outcomes and reduced costs correlate with shorter transplant wait times. Nurse case managers can implement significant interventions to decrease patients’ time on the transplant list, such as multi-listing. Multi-listing involves placing a patient on multiple waiting lists at different transplant centers, thereby increasing the likelihood of receiving a kidney transplant more quickly.
Additionally, nurse case managers must be aware of quality outcomes at multi-listed facilities. All transplant centers are required to publicly report their outcomes. It is essential for nurse case managers to verify quality data through entities like UNOS and the Organ Procurement and Transplantation Network (OPTN), which provide performance reports, as well as the Centers for Medicare & Medicaid Services (CMS), which publishes quality metrics and star ratings. Many transplant centers also share their quality measures, patient outcomes and accreditation information on their websites. Quality outcomes vary significantly by organ, making it crucial for nurse case managers to refer patients to facilities with verified standards. Failing to do so could result in choosing a facility with shorter waitlists but poorer outcomes, ultimately leading to complications. Conversely, keeping patients at local facilities with inferior outcomes could deny them access to better options available within a reasonable distance. It is imperative for renal nurse case managers to be informed about transplant quality data to effectively manage these patients and control costs.
When a patient reaches Stage III ESRD, the nurse case manager should consider evaluating them for a pre-emptive kidney transplant. A pre-emptive transplant occurs before the initiation of dialysis and is associated with improved outcomes and reduced costs. Pre-emptive kidney transplant policies allow the listing of patients with an eGFR <15 mL/min/1.73 m2, provided that the irreversibility of kidney damage is confirmed (Moura et al., 2023). However, only 10-13% of ESRD patients qualify as transplant candidates (U.S. Renal Data System, 2023).
When a nurse case manager determines that an ESRD patient will not meet transplant eligibility, the focus should shift to dialysis. This includes educating the patient on different dialysis modalities and preparing them for dialysis through the early creation of either an AV fistula or dialysis graft placement. Depending on the graft type, it may take two weeks to two months to heal and develop adequate blood flow for dialysis. Without appropriate vascular access, patients are given a temporary central venous catheter, which carries risks such as infection and thrombosis, leading to increased costs.
Due to the chronic and repeated treatments required for ESRD patients, these individuals contribute significantly to high-dollar claims. Therefore, they need compassionate and knowledgeable nurse case managers who understand the complex payer system. Nurse case managers can assist in several critical areas:
- Medicare Enrollment: Ensuring timely enrollment in Medicare when patients meet eligibility criteria.
- Preventative Care: Implementing strong preventative measures to help prevent the transition from CKD to ESRD.
- Transplant Eligibility: Verifying transplant eligibility once an ESRD diagnosis is established and facilitating pre-emptive transplants when possible.
- Multi-Listing for Transplants: Advising on multi-listing options to increase the chances of receiving a transplant.
- Quality Outcomes: Staying informed about quality outcomes at transplant facilities to guide patients effectively.
- Education for Non-Transplant Candidates: Preparing and educating patients—often with multiple comorbidities—on appropriate dialysis options, such as grafts or AV fistulas.
These critical interventions by nurse case managers can significantly improve outcomes for our renal population. The nurse case manager ensures the overall care of the renal patient is integrated and the patient is empowered to make decisions regarding their care to play an active role in their health.
REFERENCES
American Diabetes Association, & KDIGO. (2022). Consensus report: Diabetes and chronic kidney disease. Retrieved from https://kdigo.org/wp-content/uploads/2018/03/ADA-KDIGO-Consensus-Report-Diabetes-CKD-Diabetes-Care-2022.pdf.
Barzilay, A., Farag, Y. M. K., & Durthaler, J. (2024). Albuminuria: An underappreciated risk factor for cardiovascular disease. Journal of the American Heart Association, 13(2), e030131. https://doi.org/10.1161/JAHA.123.030131.
de Boer, I. H., Khunti, K., Sadusky, T., Tuttle, K. R., Neumiller, J. J., Rhee, C. M., Rosas, S. E., Rossing, P., & Bakris, G. (2022). Diabetes management in chronic kidney disease: A consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney International, 102(5), 974-989. https://doi.org/10.1016/j.kint.2022.08.012.
Dialysis PPO. (2016, October 12). The exorbitant cost of end-stage renal disease. Dialysis PPO. https://dialysisppo.com/resources/WhitePaper_101216.pdf.
Koye DN, Magliano DJ, Nelson RG, Pavkov ME. The Global Epidemiology of Diabetes and Kidney Disease. Adv Chronic Kidney Dis. 2018 Mar;25(2):121-132. doi:10.1053/j.ackd.2017.10.011. PMID: 29580576; PMCID: PMC11000253.
Moura AF, Moura-Neto JA, Requião-Moura LR, Pacheco-Silva Á. Preemptive kidney transplantation: why, when, and how? J Bras Nefrol. 2023 Jul-Sep;45(3):357-364. doi:10.1590/2175-8239-JBN-2022-0085en. PMID: 36179015; PMCID: PMC10697151.
National Kidney Foundation. (2024). Transplant waiting list. Retrieved from https://www.kidneyfund.org/kidney-donation-and-transplant/transplant-waiting-list.
SunLife. (2023, April). High-cost claims and injectable drug trends analysis. SunLife. https://sunlife.showpad.com/share/qn4HBwhB34l6lpfgmz2Qd.
U.S. Renal Data System. (2023). End-stage renal disease: Transplantation. Retrieved from https://usrds-adr.niddk.nih.gov/2023/end-stage-renal-disease/7-transplantation.
, RN, CMSRN, CCM, NE-BC, is the president of CancerCARE and has a 24-year history in healthcare. She is a board-certified nurse executive, medical-surgical RN, and Certified Nurse Case Manager. Prior to coming to CancerCARE Heidi served as a chief nursing officer and has a passion for orgnursing and leadership as it allows her to improve patient outcomes, ensure exceptional client and patient experiences & manage healthcare costs. Throughout Heidi’s career she has been awarded multiple nursing awards including Clinical Excellence In Leadership, Clinical Coach of the Year-HCA, Nursing Excellence Magazine Finalist (Mentoring), and DFW Nurses Great 100 winner. She is a graduate of Texas Tech University.
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