One area that is seeing lots of activity in terms of new value-based care models, payer-provider partnerships, and venture-backed startups is kidney disease. For this trend story, we asked several people working in this space why kidney care is ripe for innovation and why we are seeing so much progress now.
Kidney disease has been a very undermanaged disease state and involves a very costly and complex population of patients, stakeholders say. One tragic aspect is that it disproportionately impacts people of color. The National Kidney Foundation estimates that while African-American people are about 13 percent of the population, they account for 35 percent of people with kidney failure. Focusing on end-stage renal disease (ESRD), therefore, also aligns with the Biden Administration’s goals of addressing health equity and social determinants of health.
Over the last few years, the CMS Innovation Center has introduced several models that take a new approach to kidney care to address some of the inefficiencies and care coordination limitations of fee for service. The Kidney Care Choices (KCC) model launched this year is a voluntary model, and its core goal is to incentivize nephrologists, dialysis facilities and ESRD healthcare practices to focus on the total care of their patients.
The KCC model is structured to encourage participating practices to delay the onset of dialysis and instead focus on transplants. The model built upon the previous Comprehensive End Stage Renal Disease (ESRD) Care (CEC) model structure, in which dialysis facilities, nephrologists, and other healthcare providers formed ESRD-focused accountable care organizations (ACOs) to manage care for beneficiaries with ESRD. By adding strong financial incentives for providers to manage the care for Medicare beneficiaries with chronic kidney disease (CKD) stages 4 and 5 and ESRD, the goal is to delay the onset of dialysis and to incentivize kidney transplantation.
“The new model that CMMI has launched is asking providers to do things like prevention, education, social determinants of health support, and focusing on transplant as the best option. It is focused more on aggressive financial risk-taking arrangements, with an increased focus on delaying disease progression,” says Satish Cheema, chief product and strategy officer at Somatus, a value-based kidney care company that recently raised more than $325 million in a Series E financing. The CMMI model focuses on delaying disease progression, he says, and includes quality metrics that are patient-centric.
In addition to CMMI’s models, commercial payers also are creating partnerships to better manage kidney disease patients. For instance, Somatus has entered into a long-term, multi-year partnership with Anthem Inc. to change how kidney care is experienced and delivered for members of Anthem’s affiliated Medicare Advantage plans. The Anthem deal expands Somatus’ geographic footprint to 34 states and increases its kidney care lives under management to more than 150,000.
“The lack of access to care, transportation challenges, fewer educational opportunities — all of these contribute to the high prevalence of this disease in African-American patients, which is where value-based care can offer a combination of care management and the right set of medical management for managing this disease state,” Cheema says.
Another recent change is that CMS is now allowing ESRD patients to enroll in Medicare Advantage plans for the first time. “That has forced Medicare Advantage plans to look for solutions for managing this population that has always been a very high-cost, complicated population, so that was a big catalyst,” says Will Stokes, co-founder and chief strategy officer of Denver-based Strive Health.
The venture-backed Strive’s model combines technology with patient care, with the aim of slowing kidney disease progression, preventing unnecessary and costly hospitalizations, and expanding access to home dialysis and transplants. As an example of the work Strive is doing, Stokes described its partnership with Regence in the Pacific Northwest. “They are looking for our clinical solution to help them across several lines of business. We take total-cost-of-care risk on patients in their population who have chronic kidney disease and end-stage renal disease, and we get paid when we bring costs down for that population.”
One overall health system goal is to identify kidney disease earlier and intervene. That means getting primary care more involved. “When you think about CKD, it's an important opportunity to bridge the gap between primary care and nephrology,” Stokes says. “A lot of the patients who have CKD and aren't getting actively treated may have a relationship with a primary care provider. There's a big opportunity to educate those primary care physicians more directly, run analytics, and make them aware that a portion of their patients have CKD that's not being treated yet. For patients at CKD stage 3b or beyond, we can facilitate that interaction between PCP and nephrologists. Then we need nephrologists to be well incentivized and engaged in caring for those CKD patients who get referred.”
Ashok Roy, M.D., chief medical officer at Caravan Health, notes that in determining whether ESRD interventions are successful or not, payers tend to look at the number of times the patient came to the emergency department because they are missing dialysis as well as the number of ICU stays, and the number of infections. “Metrics also encompass end-of-life care, because we have pretty good data that these people don't have long lifespans,” he says. The other area where they are starting to focus is the social sphere. “A lot of issues occur outside the medical span for these people,” Roy adds. “It's a huge change in their life — it could affect their work and their finances, and transportation becomes a much bigger issue. How do we broach those subjects and help them? In a value-based contract, helping figure out transportation becomes the responsibility of the provider.”
Caravan, which was recently purchased by Signify Health, supports accountable care organizations in population health management and value-based payment programs. Many of the companies working on kidney care innovation are building predictive models to help identify those patients earlier. To do that, Roy says, Caravan needs access to EHR data. “We are in the process of building those feeds with our 300 clients,” he adds. “We focus on who will be the highest-cost patients in the next six months, so that we can target care management resources there.” The company started doing this work on COPD, heart failure, and diabetes, and is adding kidney disease to the list. “We are really passionate about leveraging data, analytics and technology to make clinicians’ lives easier.”
George Hart, M.D., is a nephrologist and chief medical officer at Interwell Health, which was recently formed by a three-way merger of Fresenius Health Partners, the value-based care division of Fresenius Medical Care North America; Cricket Health; and Interwell Health, a network of more than 1,600 nephrologists. The new company is seeking to improve kidney care and health equity by reducing hospital admissions and readmissions, slowing disease progression, increasing transplant referrals and rates, and accelerating the transition to home dialysis.
“What we've learned in the original models of value-based care with kidney disease is that there are specific strategies that you can employ to minimize hospitalizations, or more importantly rehospitalizations, by managing these transitions as patients leave the hospital and return to the outpatient setting,” Hart says. “In order to be proactive, you have to go further upstream in the life of a patient with kidney disease, where you can, put more emphasis on education, care, and helping these patients navigate that really important transition from late-stage CKD to ESRD. You can direct them toward home therapy, where their quality of life is going to be better and outcomes are going to be better. If you hit the Holy Grail, you're able to get these people transplanted before they ever see a dialysis machine.”
All the stakeholders interviewed said the CMS emphasis on health equity is especially valuable in this space, because of the disproportionate impact that kidney disease has on minorities, the elderly, and the poor. “Frequently, the challenges that we run into are because of a lack of transportation, or access to care early on, or it can be the inability just to pay for some medicines,” says Hart, “so I don't think we can be successful if we don't lean into these inequities.”
