If you are an American who has type 2 diabetes with chronic kidney disease, you must save yourself, our healthcare system is broken, and it can’t or won’t do it. I have been writing in this space almost daily for a year, to help you understand your disease, what can be done about it, and why it is worth your time. Learn about your disease and save yourself. This is especially important in patients with chronic kidney disease (CKD). While one third of patients with diabetes may have CKD, only 10% of them know it. This is a critical failure, because if these patients do not receive optimal medical therapy (OMT), half will be dead in thirteen years at an average age of 68. Making the diagnosis of CKD could not be easier, and by guideline, if you are diabetic, you should have a blood test and a urine test annually to check your kidney function.
Normal kidney filtration (estimated glomerular filtration rate/eGFR) is around 100 milliliters per minute. The blood test checks eGFR. If your eGFR is 60 or less, you need OMT now. The lower the filtration rate the greater the risk for heart attack, stroke, and dialysis. The other test is equally simple to understand. It is a urine dipstick test called the microalbumin test. If you have 30 milligrams or more of protein in your urine or your microalbumin test is positive, then you have chronic kidney disease. Either type causes roughly the same risk, and the risk is doubled if you have both types. Ask your doctor about your numbers and ask if you have CKD. If you have it, ask him to put you on optimal medical therapy, and if he won’t do it, try to help him understand, and if he still won’t do it, find another doctor. This is too important. Your life and health are at stake. Patients on OMT in this setting have one fourth as many heart attacks, one fifth as many strokes, and one sixth as many proceed to dialysis. They live eight years longer. Most patients with CKD receiving usual care die of cardiovascular disease before they go on dialysis.
Chronic kidney disease (CKD) is very common in the United States and in usual care it is relentlessly progressive in a linear fashion. One in 3 patients with diabetes has it. One in five patients with high blood pressure has it. Sixteen percent of the entire adult population has CKD and the numbers are increasing. Once chronic kidney disease begins in usual care, it is relentlessly progressive, and it is deadly. CKD patients are five times as likely to die as they are to reach dialysis. Hospitalizations are four or five times as likely in these people. With proper treatment with optimal medical therapy (OMT), hospitalizations, deaths, heart attack, stroke, and progression to dialysis can be dramatically reduced, but remember, only one in ten patients with CKD even know they have it. They cannot be doing what needs to be done. Primary care teams of nurses focused on cardiometabolic conditions and using protocols are the best answer to this problem. A powerful opportunity for patient engagement is regularly being missed.
End stage kidney disease leading to dialysis may be the mother of all health care disparities. Black Americans are four times more likely to need dialysis compared with whites. I shared call with a nephrologist in South Carolina. I have been in a dialysis clinic there. I was struck by the fact that most of the patients on the dialysis machines were black. They had not received the simple treatments for high blood pressure and diabetes that could have kept them off the machine. Black Americans are more likely to have diabetes and high blood pressure. They are more likely to be poor and to be uninsured. Patients who are privately insured on dialysis cost fourteen thousand dollars a month. That is $168,000 a year. Medicare pays an average of $90,000 per patient per year for dialysis. CKD patients make up one percent of the population and account for 7% of all Medicare costs. This situation is more than a little crazy.
Most of these patients on dialysis have diabetes and/or high blood pressure leading to their chronic kidney disease. The main components of optimal medical therapy are lisinopril or losartan, a thiazide fluid pill, amlodipine, spironolactone, atorvastatin, and metformin. The whole cocktail is about $30. We won’t pay for basic primary care for these disadvantaged patients, but they automatically go on Medicare when they need dialysis. No other advanced country has a health system like this. As soon as they need dialysis, they are eligible for Medicare, but until then many of them don’t have coverage. Taxpayers pay the bill for most dialysis. It is in the taxpayer’s interest to pay for primary care to keep these people off dialysis using OMT. Even if you don’t care about them, it is in your interest. Primary care and the required medications are chump change compared with the cost of complications. Once patients reached stage 4 (15-29 milliliters/min filtration rate) chronic kidney disease, OMT is much less helpful. The most effective medications are more dangerous then because they may cause high potassium, worsening kidney function, and they may accumulate because they are removed by the kidney, and it is failing. Identify patients with stage 3 disease and make sure they receive OMT. If you are a patient make sure you get OMT.
This is not a problem with your primary care provider. I am a primary care doctor. These providers don’t like the current system any more than you do. The current payment system does not support them in providing the care that you need, and payment to primary care is shrinking as a percentage of all spending. These providers are on a hamster wheel running from room to room to meet volume quotas imposed by the large health systems that employ them. If they don’t meet their quota, they are punished financially. No one is paid to improve your health. The more visits, tests, and procedures they produce, the more they get paid, and so they do more visits, tests, and procedures. This is a policy failure. It is a failure of medical and political leadership. It will not improve until patients and providers apply the pressure to cause medical and political leaders to make the required changes.
This failure has consequences beyond medicine. Americans realize something is wrong and our institutions do not serve them. I have laid out several examples of the ways our medical system does not serve them. They are right to be upset but they don’t understand, and in their frustration, they turn to other answers. The saddest thing is this. New science and new systems make it make it possible to slow aging and delay chronic diseases by manipulating the molecular biology that causes them. The promise has never been greater. Many of you reading this are health care leaders and educators. Join me in providing care that is really patient centered, so that we can restore the trust of the people we serve. I love the medical profession and I can’t see myself doing anything else, but we have some work to do. Please let me know if I can help you develop your OMT system. wbestermann@congruityhealth.com
Not at all surprised!
https://www.linkedin.com/posts/joseph-thomas-shen-md-b01760106_aiforgood-technologydesignedforhumans-infrastructureinvestment-activity-6897184390389342208-1CTk