A new approach to kidney care is emerging that focuses on detecting Chronic Kidney Disease (CKD) earlier, connecting patients to nephrologists sooner, and addressing patient care holistically to help ensure smoother and more coordinated care. While these objectives appear simple, it is evident that patients and providers have been navigating a fragmented system for years; one where patient care is siloed between specialties and facilities, and where payment structures end up incentivizing the number of visits and procedures over achievement of better health outcomes and the patient experience. For too long, many end-stage renal disease (ESRD) patients have been left with a limited set of options for managing their disease, due to lack of early consultation with, and guided care from, a nephrologist. According to a recent report, in 2016 an astonishing one in five ESRD patients beginning treatment had not received any prior care from a nephrologist, and one-third of patients had either never seen a nephrologist or had not received care from a nephrologist for more than six months.
Research indicates that when patients have a relationship with a nephrologist for at least one year before they start dialysis, their risk of mortality in the first year of treatment decreases by 25 percent. Furthermore, many patients never end up taking advantage of flexible options like home dialysis. In the U.S., only about 12 percent of patients are on home dialysis, as compared to higher rates globally. But as America’s health care system moves toward new models of payment and delivery, nephrology is primed to move with it.
Nephrologists can leave behind compartmentalized, volume-focused care, instead becoming the patient’s principal care provider under the structure of a value-based care (VBC) model. In doing so, the nephrologist and the patient may experience the benefits of an integrated approach that brings the promise of better value, better care, and more options for kidney patients.
Innovative Models Are Improving Outcomes and Lowering Costs
New payment and delivery models are proving that kidney disease care can be significantly disrupted in a positive manner. More nephrologists are participating and taking the lead in innovative care delivery and as a result, patient outcomes are improving, fewer patients need to be hospitalized, and cost savings are being generated across the entire health care system. New value-based payment (VBP) models are demonstrating that nephrologists can help drive and share in savings while improving patient outcomes.
Consider the success of the first phase of the CMMI Comprehensive ESRD Care (CEC) Model, which tested accountable care organizations for ESRD patients, referred to as ESRD Seamless Care Organizations (ESCOs). The CEC Model brought nephrologists and other providers together across settings to coordinate care for ESRD patients by having them take on risk for quality and financial outcomes. The goal was to have nephrologists think bigger and more boldly about their patients’ health and their needs across settings. In just the first year of the model, ESCOs generated $75 million in cost savings, a rare success for any first-year CMMI model. Better yet, ESCOs improved health outcomes, with patients six percent less likely to be hospitalized and eight percent less likely to have a catheter.[7]
Hope for the Next Generation of Models
Next generation VBP models also are on the horizon, with increased nephrologist participation key to their success. In 2019, the U.S. Department of Health and Human Services (HHS) released a bold initiative to change kidney health in America – with a goal to slow kidney disease progression, move more patients to home dialysis, and increase the number of kidney transplants.To galvanize this effort, CMS announced several optional VBP models that incentivized providers to deliver coordinated and patient-centered care.
The next generation of these models include exciting incentives and opportunities that will drive even more innovation. The Kidney Care Choices (KCC) Models are the next iterations of the successful CEC Model. The KCC models experiment with different payment and risk contracts, enhancing them through variation in participating providers and contracting entities, enhanced risk-sharing, and an expanded patient population that includes Stage 4 and 5 CKD patients, and beneficiaries with ESRD.
While the CEC model employed risk-based financial arrangements for ESCOs differentiated based on the size of the participating dialysis organizations, the KCC Models offer four payment approaches. The Kidney Care First (KCF) Option uses adjusted capitated payments, and limits eligible providers to nephrology practices and their nephrologists. The three Comprehensive Kidney Care Contracting (CKCC) options use adjusted capitated payments and allow for a variety of providers through Kidney Contracting Entities to take responsibility for patient costs and outcomes.
By including Stage 4 and 5 CKD patients and beneficiaries with ESRD, these new models intend to drive progress by creating alignment and coordination to identify kidney disease earlier and slow its advancement. Though delaying progression becomes more challenging in later stages of CKD, this program is structured to allow providers to focus resources and make improvements in this area in ways that may not be possible with fee-for-service (FFS) reimbursement.
Now is the Time for Nephrologists to Take the Lead
Moving a nephrologist’s practice away from FFS and into a value-based model can be challenging. But as more and more first-generation models report their results, nephrologists likely will see the benefits and learn from one another. We hear frequently from nephrologists participating in these models that after years of training and practice in accordance with FFS, old habits need to be “unlearned.” This takes patience and commitment. While it does not happen overnight, when practices embrace value-based care and have the support necessary to begin that transition, they can experience new flexibilities in the way they practice coupled with improved patient outcomes and reductions in the cost of care.
Furthermore, nephrologists with experience in advance payment models know first-hand that these payment models enhance as never before a provider’s ability to serve as principal care provider for patients with advanced renal disease. Interviews with nephrologists participating in ESCO’s found that the model opens avenues for care and thinking that were not always possible under FFS. Nephrologists report they’ve been able to make improvements, such as spending more time discussing disease prevention with patients, educating them about the value of flu shots, and even empowering patients to live healthier lives through nutrition and cooking demonstrations.
Nephrologists also say ESCOs incentivize better care coordination, such that their practices use new tools to understand when patients are in the emergency department and what their initial course of care was, allowing nephrologists to engage in their patients’ hospital care sooner.
Nephrologists can take advantage of this momentum to use the care coordination assets of experienced practices, and allied organizations, to help them get plugged in to these models and connect earlier with patients who are most vulnerable.
But it’s key to remember that nephrologists are not alone when contemplating a move to VBC. Stakeholders across the health care system, including payer and provider organizations such as Humana and Fresenius Health Partners, are interested in collaborating to advance this approach by supporting physicians with the resources and knowledge they need to be successful. For example, some provider-led entities, including InterWell Health, have created clinical committees and established best practices with which to assist in standardizing the care delivered to the late stage CKD population, so other nephrologists don’t have to start from scratch.
Now is the time to continue moving beyond the status quo. We know just how instrumental nephrologists are in transforming the health of patients living with kidney disease - and we're excited there are partnerships, and a path, to help them succeed in coordinating care. When outcomes are better, costs are lower, and patients are more satisfied. Everyone succeeds.
Amal Agarwal, D.O., MBA, is Vice President, Home Solutions Business Development and Strategy, at Humana Inc. Terry Ketchersid, MD, MBA, is Chief Medical Officer, Integrated Care Group, at Fresenius Medical Care North America, and the Co-Chief Medical Officer at InterWell Health.
