Looking ahead to integrated care

Is the future here now for providing optimal treatment for patients with kidney disease? Integrated care holds a lot of promise for nephrology. But there is still work to do.

Panelists at the session, “Is the future already here? Integrated care models in dialysis,” at the National Kidney Foundation’s 2016 Spring Clinical Meetings held in Boston this week, acknowledged that there were many reasons to consider a new approach to providing care to the more than 500,000 patients with kidney disease – and the 20 million people in the U.S. with some stage of kidney disease. The program originating in 1972 that offered all U.S. citizens access to kidney disease treatment has gone from an estimated price tag of $135 million a year to over $40 billion. That price tag, noted speaker Michael Shapiro, MD, always gets the attention of regulators and Congress. It swallows close to 8% of the Medicare budget while representing less than 1% of the Medicare patient population.

Shapiro noted what steps Medicare and Congress have taken to lessen that federal burden: the Prospective Payment System, or ESRD bundle, attempts to bring all of the high costs of dialysis under one bundled payment. At the same time, regulators have introduced programs like the Quality Incentive Program and the star rating system to monitor the quality of care offered by providers. Shapiro questioned the intent of the star rating system, which gives dialysis clinics a one- to a five-star rating based on performance in a series of quality measures. “If you go to a restaurant that doesn’t have an “A” rating from the Department of Health, you would walk away. Would you do that to a dialysis facility with a two-star rating?” he asked attendees. CMS has complicated things by adding vague language about the value of the star ratings. "A 1- or 2- star rating does not mean that you will receive poor care from a facility. It only indicates that measured outcomes were below average compared to those for other facilities," the Dialysis Facility Compare star ratings information page says.

Meeting quality measures

Beyond the star ratings, panelists agreed that providers have improved their performance in the QIP, and more than likely that “incentive” will be part of the Medicare physicians’ focus in the near future. Will that push more physicians into an integrated care model and lead them to becoming the captain of the ship? “There is no doubt that [CMS] is moving from a pay-for-service model to a pay-for-quality model, and they are moving as fast as they can,” said DCI’s Board chair Doug Johnson, MD.

Johnson heads up DCI’s participation in the Comprehensive ESRD Care Initiative, a five-year demonstration to test whether integrated care will work in the ESRD treatment environment. The company is taking an aggressive approach to the program, representing around 20% of the initiative’s total patient population. The sidelines are not the place to be, Johnson warned. “I’ve said this many times before: ‘When CMS is changing the rules, you want a seat at the table. If you don’t have a seat at the table, you may be on the menu."

Find more NN&I coverage of the NKF Spring Clinical Meetings

He outlined many of the potential areas for cost savings that providers DaVita Kidney Care, Fresenius Medical Care North America, and Rogesin Institute––the other participants in the demonstration––could hope to realize: $25,000 per patient in yearly hospitalization costs; $15,000 per year for each patient that gets a fistula early; the $16,000 savings realized by placing a patient on peritoneal dialysis instead of in-center care. At DCI’s Spartanburg, South Carolina clinic, for example, 73% of patients have started with a fistula; 29% of patient started dialysis at home, and 58% of patients had their first dialysis treatment in an outpatient center vs. a hospital emergency room.

Physician buy-in

But moving forward with integrated care requires physician leadership, the CMOs for Fresenius and DaVita agreed. “It’s all about physician engagement,” said Nissenson. “We are seeing the movement to value-based care: putting the patient in the center, and delivering care in the most efficient way possible.”

And the whole industry––providers, physicians, and payers like Medicare––are finally connecting the dots to make integrated care work: a new physician payment system, the flawed but worth-fixing star rating system, and the QIP. “Finally, all of the oversight, all of the regulation, is aligned” with this approach, said Nissenson. DaVita Kidney Care already has about 13% of its dialysis patients in value-based payment programs.

Clinically, we need a better understanding of the needs of the patient with renal disease, said Fresenius CMO Frank Maddux. In presenting a series of five belief statements, Maddux noted some key approaches: helping patients deal with health crises beyond ESRD; making the connection with “cardiovascular opportunities” as we do with electrolyte disorders and other ESRD-related complications, and understanding how renal disease impacts all aspects of a patient’s health profile. He noted the concept of Edit“centrality,” where nephrologists lead the treatment team. “For physicians in the future, the organized approach to care should be directed by nephrologists,” he said. -by Mark Neumann