Nephrologists Prepare for New Kidney Care Payment Models

Nov. 12, 2020
One new CMMI model addresses both CKD and ESRD beneficiaries and aligns patients based on nephrology care, not dialysis treatments

Nephrology practices across the country are gearing up to participate in new alternative payment models for kidney care that are launching next year.

The Comprehensive Kidney Care Contracting option of the Kidney Care Choices model (CKCC) is a new Center for Medicare and Medicaid Innovation (CMMI) payment innovation model that incentivizes healthcare providers to manage the care of Medicare beneficiaries with chronic kidney disease (CKD) stages 4 and 5 and end stage renal disease (ESRD). Unlike prior value-based kidney care models, CKCC addresses both CKD and ESRD beneficiaries and aligns patients based on nephrology care, not dialysis treatments. The implementation period for the program started on Oct. 15, 2020, and the official launch of the performance period is on April 1, 2021. 

In July 2019 President Trump signed an executive order called the Advancing American Kidney Health Initiative, which had some lofty goals in terms of improving the care of patients with kidney disease. As a result of that initiative, there were two models proposed by CMMI, an ESRD Treatment Choices (ETC) model, which is mandatory, and the CKCC model, which is voluntary.

 “This is an innovative model to improve the care of patients with late-stage chronic kidney disease that will improve outcomes and potentially save money for the healthcare system,” said Gary Singer, M.D., a nephrologist who leads Midwest Nephrology Associates in St. Louis.

“I am in a small practice, with three other physicians and a nurse practitioner,” he said. “What this is going to do to us and most nephrology practices is make people look further upstream at ways we can help patients at an earlier stage by means of education and using a multidisciplinary care team.”

Singer said that in moving toward a value-based care system, “if you can see these patients early enough and give them appropriate care, you can get better outcomes for the patients and it is going to be recognized by CMS and CMMI and get reimbursed for doing the right thing. It is an alignment of financial incentives both for the payers, healthcare systems and providers.”

Because his nephrology group is small, Singer is partnering with a large local system, SSM Health, as well as Denver-based Strive Health, a national company focused on value-based kidney care. “We see Strive as an extension of our practice, as a partner,” Singer said. “Since we are small, we don’t have our own data analytics department. It is a huge benefit to us.”

Through partnerships with nephrologists and direct care arrangements, Strive manages thousands of complex CKD and ESRD patients in five states, and the company said it will be managing, or supporting the management of more than 30,000 patients in 12 states by early 2021.

 “Strive was founded in October 2018 with the goal of creating a care model that really encompasses managing patients across the entire disease spectrum,” said Shika Pappoe, M.D., the company’s chief medical officer.  “To date, much of kidney care has been focused around the late-stage patients, but we know the goal is to intervene early so you can slow progression and educate and empower patients to make decisions around their own care,” she said. As much as we want to slow progression, we know there are patients who move to ESRD. Our goal is to prevent folks from crashing. Today, upwards of 80 percent of patients who transition to ESRD are actually crashing into hemodialysis. We know there are other options available to patients, including pre-emptive transplants, home dialysis and in some cases palliative or conservative care.”

She described Strive’s program as being designed with an interdisciplinary team that includes nurse practitioners, care coordinators, care managers, social workers, clinical pharmacists and dieticians. “We know this is critical because these patients are incredibly complex. And the capacity and resources we bring really allow us to wrap our arms around these patients and be a safety net and help them navigate what is a very complicated healthcare system,” she added. “We plug into nephrologist practices as an extension and bring this care team to co-manage education, shared decision-making processes, and supportive management of co-morbid conditions. A lot of those are what drive the hospitalizations of CKD and ESRD patients. The goal is to keep the focus on holistically managing the patients entire chronic disease spectrum.”

Strive also applies a proprietary data science model to patient populations for risk-stratifying patients. “Because this program is heavily resourced, we have to be strategic and thoughtful about how we deploy those resources,” Pappoe said. “Data analytics really helps us scale.”

Among the quality measures included in the new model are things like a patient activation measure, which reflects how well patients are educated and activated in their care, as well as a metric around behavioral health support.

Strive hires clinicians in each market it is working in and builds care hubs — locations where clinicians are co-located. It also has a mobile component. “For our highest-risk patients, we send nurse practitioners and social workers to homes or skilled nursing facilities,” Pappoe said. “And during the pandemic, we also have leveraged telehealth resources.”

Describing the potential of the new payment model, Singer said, “Historically we have worked in a fee-for-service world, and I don’t think that is sustainable. Patients with chronic disease and end-stage kidney disease account for a disproportionately large amount of healthcare dollars from Medicare and despite most of what we have done, the outcomes haven’t really changed, so I think we need to change the care delivery model.”

He noted that in the past the different parts of Medicare have been treated in a siloed way. But we may have to spend more on certain types of drugs in order delay progression of kidney disease and save money in other parts of the health system.

Pappoe said there has been a shift in the kidney space, and there is a lot of excitement and momentum. “Our company is very eager to work with the many nephrologists who want to be innovative,” she said. “We know that when we can deploy these models that are designed for value-based care, we can do some innovative work. At the end of the day, it is about the patient, and I think these models allow us to take a much more holistic approach as opposed to a siloed approach that they have experienced. I am really excited about that. It is going to allow us to intervene earlier in the patient’s journey and empower them to do better.”

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