The CDC estimates that 37 million people in the United States have chronic kidney disease (CKD), and more than 726,000 have end stage renal disease (ESRD). In 2017, treating Medicare beneficiaries with CKD cost over $84 billion, and treating people with ESRD cost an additional $36 billion, according to the CDC. An ongoing issue, related to both cost and quality, is that kidney care has been traditionally focused around the late-stage patients, with incredibly high costs associated with patients who “crash” into dialysis.
Thankfully, recent efforts at the federal level aim to transform approaches to kidney care treatment by encouraging providers to intervene early and provide more holistic care for patients. Last fall, the Center for Medicare and Medicaid Innovation (CMMI) finalized the structure of a payment innovation model that puts into place strong financial incentives for healthcare providers to manage the care of Medicare beneficiaries with CKD stages 4 and 5 and ESRD. The program, Kidney Care Choices (KCC), is a voluntary alternative payment model and its core goal is to incentivize nephrologists, dialysis facilities, and ESRD healthcare practices to focus on the total care of their patients. According to the Centers for Medicare & Medicaid Services (CMS), more than 430,000 Medicare fee-for-service ESRD beneficiaries spend an average of 12 hours a week receiving dialysis at a center, so the KCC Model is structured to encourage participating practices to delay the onset of dialysis and instead focus on transplants.
Taking a step back, in July 2019, then-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, one of them being the Kidney Care Choices program.
Oftentimes when CMMI unveils different payment models for fee-for-service members, Medicare Advantage (MA) plans follow suit and introduce similar programs, explains Heidi Syropoulos, M.D., medical director for government markets at the Philadelphia-based health insurance company Independence Blue Cross. So, in December, Independence announced the launch of a new program for the insurer’s MA members living with chronic kidney disease stages 4 and 5 and end stage renal disease. The goal of the program, which commenced on Jan. 1, 2021, is to slow disease progression and improve quality of life for these members by assisting with disease and care management and reducing unnecessary hospital stays, health plan officials stated. “We need fewer Americans receiving dialysis in dialysis centers, and we need more kidneys to be transplanted,” says Syropoulos. “[The Trump administration’s] 2019 executive order was big and bold, and it said, ‘Let's face it, kidney care treatment in the U.S. is really suboptimal. It costs a lot of money, patients have a poor quality of life, and we can do better,’” she asserts.
However, for Independence, despite recognizing that the insurer’s dialysis members were very expensive kidney care patients, there still wasn’t a high number of them connected to its Medicare Advantage plans, Syropoulos notes, as previous restrictions have prevented most Americans with ESRD from enrolling in MA plans. But thanks to a small provision in the 21st Century Cures Act, starting Jan. 1, 2021, all Medicare-eligible individuals with ESRD are now able to enroll in MA plans. This has been considered by many industry groups as a welcomed change, as while most Medicare beneficiaries have an array of coverage options, individuals with kidney failure have historically faced fewer choices and potentially large out-of-pocket costs due to the expensive nature of kidney dialysis.
With the current enrollment restrictions lifted via the Cures Act, CMS now estimates that an additional 83,000 people with ESRD will enroll in MA by 2026, which represents an increase of 63 percent. For Independence, previously, the only dialysis members on the books were people who came to the insurer and who did not have end stage renal disease yet, but ended up developed it later. “Now, we could have many members choosing us right off the bat. So we realized that we may have more members coming to us, and we knew we had to get our arms around how we're going to be able to take care of these folks,” Syropoulos says.
Finding a partner in Strive Health
Looking to team up with an expert in nephrology care, Independence turned to the Denver-based Strive Health, a national company focused on value-based kidney care. 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 soon be managing, or supporting the management of more than 30,000 patients in 12 states. In this specific program, Independence’s MA members will receive care from Strive Health’s local team of nurse practitioners, registered nurse care managers, social workers, dietitians, pharmacists, and care coordinators. The care includes disease management, wound care, medication management, acute care management, and more. To help ensure this care is effective, the Strive Health team coordinates with the member’s primary care physician, nephrologist, and any other specialists the member may be seeing, officials explained.
Speaking to the decision to partner with Strive, Syropoulos references the company’s “incredible breadth of understanding” the specialty, noting that almost all of their senior leadership has worked at either DaVita or Fresenius, two of the largest players in the kidney care space. “They knew kidney disease inside and out, they knew disease management, they knew care management, and their medical director, Dr. Shika Pappoe, ran the kidney care program at CareMore,” an integrated health plan and care delivery system for Medicare and Medicaid patients, Syropoulos says in her recounting of meeting with Strive’s executive leaders.
Together, the companies were aligned in what they wanted to accomplish around disease and care management services in order to delay disease progression, reduce unnecessary inpatient utilization, improve patient mortality and morbidity outcomes, and reduce crash dialysis, which is one of the biggest kidney care spends, Syropoulos says. She notes that while the insurer has previously spearheaded quality incentive programs with its primary care practices, it has never had an incentive program specific to a specialty group.
Enter Independence’s nephrology pay for value (NeP4V) program that started Jan. 1 and will give nephrology practices an opportunity to earn incentives for continually improving the quality of medical care and service they provide Independence commercial and Medicare Advantage members with advanced CKD stages 4 and 5 and ESRD. According to officials, payment incentives will be based on several factors: how well a nephrology practice performs relative to other qualifying participating nephrology practices; the practice’s performance compared to all participating practices to determine the practice rank; and the practice’s evaluation on its performance relative to defined kidney care measures.
Syropoulos says the idea was to structure the program similar to how CMMI’s Kidney Care Choices model is shaped, which entails a number of measures: looking at the number of kidney transplants, with a bonus for the number of patients who actually get transplanted and stay off dialysis for 12 months; the percentage of patients who are getting their dialysis at home; and the percentage of patients who have a planned dialysis start—so all those patients whose first claim of dialysis is not in the emergency room or the hospital—which is essentially an inverse way of measuring crash dialysis, she explains.
One advantage of having this model closely aligned to CMMI’s KCC model is that nephrologists in Southeast Pennsylvania who have opted into that model of care with CMS are already monitoring these elements with their fee-for-service Medicare members, Syropoulos notes. “So we're going to try and incentivize them and see how well they can do, and we’ve set up a fairly robust reporting system for them, as well as way for them to track their progress through a portal,” she says.
What’s more, Independence has also started to introduce the nephrologists to Strive via meetings where the insurer’s leaders are informing their kidney care doctors of the nephrology incentive program, while also telling them about Strive, “which is a new disease and care management service program that works like somebody in your back pocket,” as Syropoulos puts it. For example, she adds, Strive digs into important questions for nephrologists and patients, such as: Do you need someone to go into the home? Do you need social services? Would you like a pharmacist to speak to the patient? “There is actual disease management. Strive, of course, has nurse practitioners that can see patients pretty much wherever they are. But the big thing will be that Strive will help the nephrologists managing these patients, which in turn can help the nephrologist with their incentive program,” says Syropoulos.
To that point, Syropoulos believes that one of the most exciting aspects of the relationship with Strive is that they have a very robust care management program with social workers who truly attend to, review, and try to break down barriers of patients’ social determinants of health. “So they are managing not just the kidney care, but they are essentially going to be doing case management for these patients for everything and anything else that they need. And to do that, they have to be coordinating with the primary care physicians,” she says.
Syropoulos additionally notes, “Strive is at risk for all of these members—all the Medicare Advantage members, CKD stages 4 and 5, and ESRD—and there's a shared savings arrangement with them once they hit a certain benchmark. So we are hopeful, and it’s why we are so proud to be working with an organization that we believe will deliver the preventive, personalized healthcare our members with chronic kidney disease and end stage renal disease need and deserve.”
