HHS's Kidney Care Plan Targets Dialysis Chains and Nephrologist Ties. None of Its 23 Recommendations Has a Deadline.
Released Oct. 20, the plan flags nephrologist directorships and post-contract limits and urges CKD screening. Its 23 recommendations set no dates.
The Department of Health and Human Services' Kidney Care National Plan, released Oct. 20, sets three priorities, preventing kidney failure, opening the dialysis market to competition and reforming transplantation, but its 23 policy recommendations are proposals to study or consider, with no deadlines.
The 17-page plan, published by the HHS Office of the Assistant Secretary for Planning and Evaluation, builds on the 2019 executive order Advancing American Kidney Health. It arrives with large numbers attached: an estimated 37 million adults with chronic kidney disease, 87 percent of whom do not know it; about 831,000 Americans living with kidney failure in 2023; and roughly 90,000 people on the kidney transplant waiting list.
What does the plan say about nephrologists?
It names physician relationships as part of the competition problem. The plan says dialysis chains "build strong financial relationships with nephrologists through medical directorships, joint ventures, and value-based care partnerships" that discourage referrals elsewhere, and that some contracts restrict physicians from working with other suppliers after the contract ends. It does not propose a specific rule on those arrangements; it says CMS should work with federal partners to investigate anticompetitive strategies.
The plan puts the two largest chains' share of the dialysis market at about 59 percent in 2006 and about 74 percent in 2026, and says that as of 2019 roughly one third of the U.S. population lived where the only dialysis supplier was one of those two firms. It says private insurers pay up to 500 percent, and Medicare Advantage plans up to 25 percent, more than traditional Medicare for dialysis. It also recommends that HHS consider having charitable premium-assistance programs, which can help dialysis patients keep commercial coverage instead of moving to Medicare, reviewed for fraud or violations of federal law.
For nephrologists, the plan is a signal about where scrutiny is heading, not yet a rule they must comply with.
What does the document commit HHS to do?
Very little, on its own terms. By The Script Pad's count of the plan's recommendations section, 19 of the 23 items say HHS "should consider," two say HHS "could" explore or consider, one says HHS "should examine" alternative dialysis settings, and one says the Health Resources and Services Administration "should continue" carrying out existing living-donor law. None names a date, a rulemaking or a funding amount. The Healio report on the launch and Home Health Care News described the priorities; neither reported implementation timelines.
The prevention recommendations are the most clinic-facing: a systematic evidence review on screening people with diabetes, hypertension, cardiovascular disease or a family history of kidney failure; a provider toolkit on newly approved therapies; and possible payment models. The plan says the CMS Innovation Center could test a model rewarding earlier CKD care and cites the ACCESS Model as an example.
How far has home dialysis moved?
About 16 percent of dialysis patients were treated at home in 2023, up from 10.5 percent in 2017, the plan says. By our arithmetic, that is a gain of 5.5 percentage points over six years, a little under one point a year. The plan also says the ESRD Treatment Choices Model was terminated after it did not achieve its intended outcome or anticipated savings, while the Kidney Care Choices Model, launched in 2022, is scheduled to run through 2027.
Dialysis providers welcomed the plan. Fresenius Medical Care said in an Oct. 20 statement that the plan's focus "aligns closely" with its mission, and Colin Roskey, executive director of Kidney Care Partners, said the plan "appropriately recognizes the regulatory burdens for dialysis providers," Healio reported.
What to watch
The plan's force will depend on what CMS and HRSA propose next; the document itself points to Innovation Center payment models and tighter oversight of organ procurement organizations. Nephrologists with dialysis medical directorships or joint ventures should know what their contracts say about exclusivity and post-term restrictions, as federal attention to concentrated health care markets and physician noncompetes grows. Primary care practices can act now on the plan's least contested point: by its estimate, most CKD is undiagnosed, and finding it in patients with diabetes, hypertension or cardiovascular disease does not have to wait for a federal model. Nephrology readers may also want our coverage of the ravulizumab approval in IgA nephropathy.
Reported, fact-checked and edited by The Script Pad's editorial staff. See How we use AI.
This article is for professional education and does not replace clinical judgment. Treatment decisions should be based on the individual patient and current guidelines.
