Health equity is an important goal for the U.S. health care system, though one it is still far from achieving. That means providing every person with the same opportunity to receive high-quality care, regardless of their income or race.
According to the Robert Wood Johnson Foundation, achieving health equity requires “removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
Achieving health equity at a local level is challenging. Doing so consistently at a national scale is rare. Yet that is exactly what one U.S. health care sector — dialysis care — has been doing, substantially outperforming many other sectors of this ecosystem. The kidney community has overcome socioeconomic barriers and is reliably delivering excellent clinical outcomes regardless of where dialysis centers are located and who they are caring for.
How? By offering accessible care that uses a standard set of services, integrates social and nutritional support into treatment, and maintains a mindset of continuous quality improvement.
People experiencing kidney failure (also known as end-stage renal disease) need dialysis to do what their kidneys can no longer do — remove waste and extra water from the bloodstream. There are several types of dialysis treatment options available to patients, and each requires dedicating significant time to the process. Patients choosing to treat in a dialysis center, for example, receive dialysis treatments three times a week for up to four hours per treatment. Others do dialysis at home with different, but still lengthy, frequency.
Dialysis was initially offered as a rationed, hospital-based treatment. Over the last 50 years, however, it has evolved into a readily available, safe, and effective outpatient therapy, whether administered in the home or in specialized dialysis centers. There are approximately 7,350 such centers in the U.S., operated by a range of providers, from large, multistate organizations to small, single-site providers.
Everyone needing dialysis receives quality care regardless of gender and social or economic status. This approach has contributed to improved outcomes for dialysis patients over the years. For example, data from the United States Renal Data System (a National Institutes of Health registry) demonstrate a dramatic reduction in death rates among dialysis patients for all races from 2005 to 2015 (the last year for which complete data are available). This improvement happened in the absence of any new breakthroughs in drugs or devices used in dialysis technology and with a population that is older and sicker than previous generations.
In the general Medicare population, as well as among individuals with advanced chronic kidney disease who do not need dialysis, African Americans are more likely to be hospitalized than Caucasians. But among those with kidney failure who require dialysis, African Americans’ risk of hospitalization is the same as that among other racial groups.
Analyses of Medicare’s publicly available Five-Star Quality Rating data, conducted by my company, show that across a spectrum of socioeconomic circumstances (food environment, unemployment, high school graduation, and severe housing problems), dialysis centers achieved more consistent and equitable quality results than hospitals.
As an example, consider two dialysis clinics: one in a Chicago neighborhood with a 24.3% poverty rate and a median income of $38,417, the other in suburban Leawood, Kan., with a 1.9% poverty rate and a median income of $109,670. Given their socioeconomic differences, a corresponding difference in clinical outcomes might be expected. But both have very similar standardized hospitalization rates.
The similarity in outcomes across various geographic and health equity factors in this example are mirrored across the industry as a whole. It is the result of having the same clinical expectations, employing the same clinical protocols, providing clinicians with the same training, and continuously allocating resources to improve the outcomes of lower-performing centers.
A number of factors help the U.S. kidney care community come closer to achieving nationwide health equity than other health care sectors:
First, dialysis patients automatically receive a broad bundle of associated services, medications, and labs. This health care sector was one of the first to embrace a payment-for-performance system, which provides incentives for providers to pursue and achieve high-quality care.
Second, the United States Renal Data System covers a variety of socioeconomic factors, including race, income level, and rural versus urban location. This information helps ensure that potential differences in quality outcomes by socioeconomic levels are transparent to the public. These data serve as a benchmark to encourage providers to consistently improve the quality of care they deliver.
Third, consolidation across the dialysis industry has created economies of scope and scale, which has allowed for an increase in professional training for staff, more sophisticated information technology systems, and a greater ability to improve clinical outcomes and access to care. Over the last few decades, the dialysis industry has expanded its capabilities for population health services like predictive analytics and care coordination, reduced health care-acquired infections, and invested in new digital patient engagement strategies that improve outcomes and patients’ experiences.
The kidney care community has become a learning health care system in which data analysis and idea sharing generate the development of best practices that are then quickly cascaded into patient care. The output of these efforts are then tracked and reported in quality programs and are regulated through a consistent federal certification process, ensuring all patients receive the same level of quality care.
Applying this approach to other diseases, like diabetes or cancer care, has the potential to improve outcomes across the board.
Efforts to achieve quality outcomes through the kind of value-based care delivered by dialysis centers should extend beyond traditional health outcome measurements, like dialysis adequacy and immunization rates, to include all aspects of patient health, including disease prevention, behavioral health, and management of non-renal conditions. If existing dialysis programs were to take accountability for all of their patients’ hospitalizations and health care expenses, health equity could be realized at an even greater level.
Achieving equity in all areas of health care will require new innovations for providing individualized patient care and medications, educating family members, and integrating social services. All of these interventions can help improve anxiety, depression, and many other aftereffects of kidney failure. And what we learn from such efforts could help improve health equity in depression and other mental health issues, substance abuse, and nutrition.
The kidney care community is already a national leader in health equity, and we think it can be a role model for other specialties. As the payment system switches from paying for treatment to paying for outcomes, it can have an even broader impact, helping pave the way for the treatment of other chronic conditions that disproportionately affect the lives of those who are socioeconomically challenged.
Kent Thiry is the chairman and CEO of DaVita Inc., which operates dialysis centers across the U.S.