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Clinical and economic disparities between CKD and ESKD care

Issue: April 2019

ByNupur Gupta, MD

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Chronic kidney disease is a growing public health problem in the United States. Dialysis and kidney transplantation are the only available life-prolonging treatments for patients with ESKD. While the incidence ESKD has stabilized, the prevalence and expenditures for these patients continue to increase. This has generated significant financial pressure on Medicare.

The overall prevalence of CKD increased from 12% to 14% between 1988 to 1994 and 1999 to 2004, but has remained relatively stable since 2004.¹ In general, and not surprisingly, rates of hospitalization among patients with CKD have increased in the presence of underlying comorbidities, such as diabetes mellitus (DM) and cardiovascular disease (CVD).²

Source: Rajat Kapoor

Since 1973, when Congress enacted legislation covering the costs for ESKD care under Medicare, growth in the dialysis and kidney transplant population has been remarkable. In the succeeding decades, there has been a steady increase in number of people initiating dialysis with eGFR greater than 10 mL/min per 1.73 m² to 15 mL/min per 1.73 m².

The incidence of ESKD, adjusted for age and sex, initially started stabilizing from the early 2000s, then started declining for reasons that need to be explored. Even though incidence continues to decline, 359 patients per 1 million patient population transition to dialysis or transplant each year in the United States.³

McCullough and colleagues developed projections to 2030 for the ESKD population — the longest projection to date — using a population-based transitional model which considers obesity and diabetes rates and the aging of the general population in the United States. Based on these assumptions, their predicted range for the ESKD population is 971,000 to 1,259,000 patients by 2030.⁴

Burden of CKD

Chronic kidney disease is a complex condition associated with other chronic diseases, including DM, hypertension (HTN), chronic liver disease, CVD and cancer.⁵ Cardiovascular disease remains the leading cause of death in the United States and most other developed countries.³ Most patients with non-dialysis dependent CKD (NDD-CKD) die from CVD before progressing to ESKD.⁶ Chronic kidney disease is identified as an independent risk factor for CVD.⁷ As median survival is continuously improving for all these chronic diseases, a possible reason for the increasing prevalence of ESKD is that an increasing proportion of patients with NDD-CKD survive until they need dialysis. Other factors like health technology, diagnostics and medications add to the expenditure. Non-medical factors like patient loss of employment, loss of work by caregiver, transportation, psychological and physical are the unmeasured financial burden and societal cost of both ESKD and NDD-CKD.

According to data from the U.S. Renal Data System, Medicare spending for all beneficiaries who had CKD (12.5% of total) exceeded $79 billion in 2016, an increase of 23% from 2015. When adding an extra $35 billion for ESKD costs, total Medicare spending on both NDD-CKD and ESKD was more than $114 billion, representing 23% of total Medicare fee-for-service spending.

The costs of care for patients with NDD-CKD is also increasing rapidly — even in the early stages of the disease. In 2016, Medicare spending for beneficiaries with NDD-CKD aged 65 years and older exceeded $67 billion, representing 25% of all Medicare spending in this age group and an increase by 15% from 2015. Patients who progress to ESKD currently account for as much as 6% of Medicare spending despite such patients only making up 1% of the Medicare population.⁸ They both have significant health care cost to society, with each type varying the amount of burden. The annual cost to Medicare for a patient on dialysis is $88,000, which is more than the cost of care for patients in late stages of NDD-CKD.⁹ Before ESKD develops, the cost of NDD-CKD care increases substantially with the need for access placement, likely hospitalizations, loss of employment and other medical complications. As noted above, even though the incidence of ESKD is decreasing globally, prevalence continues to increase. At the same time, the current population will get older and sicker, adding to the financial cost.

There is worldwide consensus that the cost and economic burden of ESKD may become unsustainable. Strategies and interventions are needed that take into consideration that NDD-CKD is part of a continued spectrum of ESKD, not in isolation. Non-dialysis dependent CKD lacks its own quality measures and attention from public policy. Most of the attention in the kidney disease space is focused on reducing the cost of ESKD, with little attention given to NDD-CKD.

Discussed below are the multiple deficiencies in the current model of care with potential solutions (see Figure).

Financial compensation

Medicare pays the treating nephrologist a monthly capitated payment (MCP) once a patient start dialysis. Beginning in 2004, CMS implemented a tiered fee-for-service payment system, based on the number of face-to-face visits per month, with payment ranging from $188 to $288 per visit.¹⁰ In contrast, for outpatient NDD-CKD visits, CMS pays for office visits on a fee-for-service basis per visit. The MCP in the dialysis clinic is substantially higher than office visit reimbursement.

The goal of the tiered MCP payment was to increase patient physician interaction in the hope for improving quality of care. The payment disparity could have created unforeseen incentive for the physician to spend his or her finite time seeing patients on dialysis. Patients with an early referral to nephrologists have slower rates of GFR deterioration, have shorter hospital stays associated with dialysis initiation, are more likely to have a permanent vascular access and receive peritoneal dialysis, and have an approximately 30% lower mortality rate at 3 months and 5 years after dialysis initiation.¹¹

Studies have demonstrated health cost reduction and improved outcomes with appropriate transitions to renal replacement therapy (RRT) by use of vascular access, reduced hospitalization and starting PD.^12,13

Needed infrastructure

The current fee-for-service model limits the ability to invest in this needed infrastructure. Dialysis units have various personnel and financial resources at their disposal, making it easier for physicians to start a patient on dialysis than to continue to follow the patient in the clinic.

The increasing medical and social complications in the patient with advanced NDD-CKD, the lack of infrastructure to adequately address these complications in a typical NDD-CKD clinic setting and the financial MCP reward for starting a patient on dialysis may tip the balance toward dialysis initiation for reasons that may not be in the patient’s best interest. Economic considerations that automatically qualify almost all patients with ESKD for Medicare within 3 months of dialysis initiation also may contribute to this decision-making process.

Conservative care

Patients with non-dialysis dependent CKD have an increased risk of death before progressing to ESKD compared to matched patients without NDD-CKD.¹⁴ The benefit of renal replacement therapy (RRT) for all patients with CKD remains questionable, particularly for patients older than 75 years with ischemic heart disease and multiple comorbidities. Some studies have shown starting dialysis may not increase lifespan and may put the patient at higher risk for complications from their other comorbidities.¹⁵ For these patients, dialysis is unlikely to improve their symptoms and may negatively influence their health-related quality of life and functional status.¹⁶

Compared with those managed medically, older patients on dialysis spend more time in the hospital and are at increased risk for infectious and cardiac complications of dialysis.¹⁷ Only patients with fewer comorbidities survive longer with dialysis than conservative treatment.¹⁸

Change needed

Given the observation and experience with dialysis not being beneficial for every patient, there needs to be a change in the traditional paradigm of dialysis for almost all patients with ESKD. Multiple professional societies have recommended tailoring care according patients’ needs and discussing the benefits of RRT.¹⁹ A KDIGO consensus conference in 2013 recommended a conservative care approach for patients who will unlikely benefit from dialysis.²⁰

The difficulty is to find balance between over treatment and withholding treatment. The current conservative management programs have variability of support (eg, in funding, infrastructure and human resources). As compared to other developed countries, the United States lacks infrastructure support and studies assessing the conservative care approach.

Prevention of CKD

Development of strategies that include screening for slow progression of NDD-CKD seems to be untargeted despite their potential to reduce the cost of kidney care. Notably, health economic studies demonstrating cost reduction with preventative measures are scarce. Programs to screen for CKD have proven effective in reducing costs only in high-risk population followed by angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapies. ²¹

Primary prevention aims at modifying risk factors that lead to CKD such as DM and HTN. Lifestyle change seems to be the most effective strategy with minimal effort for most chronic diseases including CKD.²² Addressing these factors could have a major impact on incidence of CKD.²³ Although there could be concern about increased societal cost with these preventative measures and increased longevity of the population, the resulting decrease in burden of illness should more than make up for that cost. The most cost-effective strategy would be to develop interventions applied early in disease process that are focused on the most vulnerable populations and which are accompanied by cost and outcome measures to demonstrate value.

The public health significance of CKD lies not only in the progression to kidney failure, but also with the associated excess in cardiovascular mortality. Glycemic control, delay in development of albuminuria and HTN control have not only shown benefit in CKD but also on CV mortality. Renin angiotensin aldosterone system (RAAS) blockade is the cornerstone of the therapy in this regard. However, the benefits both to kidney and heart are often sacrificed when potentially treatable hyperkalemia or selflimited hemodynamically mediated GFR reduction prompt discontinuation or reduction of RAAS blockers.^24,25 RAAS blockade is not optimized when the medications are curtailed due to an increase in serum potassium or creatinine level.

Better coordination of care between nephrologists and other health care providers, such as primary care physicians, cardiologists and diabetologists, may help mitigate some barriers to renal protection. Various other strategies have shown to reduce progression and CV mortality, but studies are lacking that demonstrate which alternatives showing similar efficacy are most cost-effective.²⁶

CKD model

Value-based purchasing began in 2008, with the passing of the Medicare Improvements for Patients & Providers Act. That legislation lead to implementation of the ESKD Quality Incentive Program (QIP) in 2012. Dialysis units are reimbursed for performance depending on the quality score, with penalties capping at 2%. In 2015, the Medicare Access and Chip Reauthorization Act established the Quality Payment Program (QPP), which introduced the Merit-based Incentive Payment System and the Alternative Payment Model structures to physician reimbursement. These new value-based payment structures were designed to measure and pay eligible clinicians based on quality, resource use, clinical practice improvement, and promoting interoperability.²⁷ The ESKD Seamless Care Organization (ESCO) developed by Medicare and the Clinical Episodic Payment models by the Renal Physicians Association are models for ACOs and for ESKD currently in trial. The quality measures in ESCOs and ESKD QIP focus on patients on dialysis. ESKD Seamless Care Organization participants (nephrologists, dialysis providers and other entities) are responsible for clinical quality and financial outcomes measured by Medicare Part A and B spending. There benchmarks are established by CMS.

If the cost of care for attributed beneficiaries is less than the benchmark, the ESCO participants can share savings with Medicare. Excess cost is shared among participants with Medicare in the double-sided risk models which involve only the large dialysis organizations. Higher quality scores incentivize the ESCO for profit sharing. Currently, there are 37 ESCOs participating in the Comprehensive ESRD Care Model.²⁸ See Table for a list of payment models.

Most of the innovation for quality and cost savings has been in the area of ESKD care, not NDD-CKD care.

New payment methods

There needs to be new payment models that align incentives across all stakeholders to realize savings and outcome improvements across the continuum of CKD care. Medicare should expand its chronic conditions needs plan to CKD stage 4 to 5 for improving coordination of care. This would involve development of evidence and validated quality measures for integration into the current ESKD QIP. Using a shared-savings model similar to ESCOs, the sharing of savings for patients with NDD-CKD (compared to the high Medicare fee-for-service costs noted earlier in this article) will incentivize providers to invest in the infrastructure needed to provide care coordination between all medical disciplines, to provide care coordination across the continuum of care between NDD-CKD and ESKD, to place greater emphasis on CV risk reduction, to integrate electronic healthcare record systems, and to increase the use of non-physician providers to reduce emergency room visits and hospitalizations. The same shared savings model will incentivize payers to decrease the burdens on physicians and health care systems that do not result in improved patient outcomes.

Collaborative care is the cornerstone for patients with NDD-CKD; they have multiple comorbidities which require the care of multiple providers. All providers, including primary care and other specialists, must be accountable for a NDD-CKD payment model to succeed, which means they must all have “skin in the game.” An ACO which involves many physician practices within a region or health care system may provide this accountability, but models need to be developed to promote the most cost-effective care for patients with NDD-CKD who are not in ACOs.

The disproportionate amount of Medicare expenditures on patients with ESKD has attracted considerable attention from health care economists and policy makers. There has been a relentless effort to reduce the cost with various policies and payment models, none of which has proven particularly successful as of now. No root cause analysis for the exploding costs of ESKD care has been published, which should be the first step in addressing a systemic problem.

The goal to date has been to provide the most cost-effective dialysis care instead of delaying the progression of CKD, identifying patients at risk and engaging them for lifestyle modification, education and interventions to slow the rate of CKD progression and decrease CVD. The REACH program by Dialysis Clinic Inc. was established 2010 to enhance coordination of care. This program enrolls patients with eGFR less than 60 mL/min for secondary and tertiary prevention.¹²

It would be useful for pilot programs like this to be implemented to different geographical areas to assess their adaptability to varying patient demographics and health care systems. Financial models have shown benefit with intervention in CKD stage 4 yielding a net health care cost savings of $0.73 billion per year in 2016 United States dollars for Medicare alone (range, $0.25 billion to $1.37 billion per year) and $1.36 billion per year for all payers (range, $0.45 billion to $2.46 billion per year). More than 60% of net savings would come from reducing inpatient dialysis initiation.⁹

Conclusion

Incentives for coordination of care and integration of advanced NDD-CKD with an ESKD payment model may improve outcomes while reducing cost. Rethinking and redesigning the CKD-ESRD care continuum as opposed to only ESKD care has potential to reduce cost and improve patient and provider engagement to provide the best possible care.

• References:
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• 24. Mathews R, et al. Am Heart J. 2015;doi:1016/j.ahj.2015.03.019.
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• 27. Value Based Programs. www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html.
• 28. Comprehensive ESRD Care Model https://innovation.cms.gov/initiatives/comprehensive-ESRD-care/ Accessed Jan. 18, 2019.

• For more information:
• Nupur Gupta, MD, is a nephrologist with Indiana University Health Physicians in Indianapolis. She can be reached at nugupta@iu.edu.

Disclosure: Gupta reports no relevant financial disclosures.