Primary care intervention through commercial health plan may improve CKD management, reduce costs
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A quality improvement intervention — integrated into BlueCross BlueShield’s CareFirst patient-centered medical home model — provided benefits to patients with advanced CKD, including decreased hospitalizations and reduced medical costs.
“In general, improvements in care quality, patient outcomes and the cost-effectiveness of care can arise through the process of continuous quality improvement and the implementation of population health management models that leverage health informatics, team-based care, and strategies for organizational change,” Joseph A. Vassalotti, MD, chief medical officer at the National Kidney Foundation and clinical associate in the department of nephrology at Icahn School of Medicine at Mount Sinai, and colleagues wrote. “CareFirst initially determined CKD as frequently underdiagnosed and elevated serum creatinine as the most significant laboratory cost driver across the member population compared with other laboratory tests, including hyperglycemia, hypercholesterolemia and liver function test abnormalities. CareFirst then began collaborating with CKDintercept, the CKD primary care initiative of the National Kidney Foundation (NKF), to design a quality improvement study to test the impact of a CKD intervention in the primary care setting.”
The study included primary care physicians who voluntarily participated in the program and 7,420 CareFirst beneficiaries (38.2% with diabetes and hypertension) in the Washington D.C. area. The intervention was meant to improve detection of CKD, testing in at-risk populations and the individualization of care plans for patients based on risk stratification (determined through eGFR and urinary albumin-creatinine ratio [uACR]). Additionally, long-term goals of the study included promoting CKD diagnosis, reducing cardiovascular risk, slowing CKD progression, increasing timely nephrology consultation and reducing costs.
To achieve these goals, PCMH leadership, case managers and care coordinators were trained by the NKF on related strategies, and care coordinators helped participating physicians identify, screen and monitor patients who had indicators of CKD. Kidney care testing quality measures were also used to evaluate physician performance.
At the end of the intervention, while there was no change in eGFR testing among risk groups, researchers observed an increase in uACR testing. They argued that, compared with eGFR, uACR is “more specific to kidney disease testing [but], unfortunately, less commonly ordered.”
Further, there were reductions in hospital admissions based on different risk categories (362.5 to 249 per 1,000 patients for class 3 and 590.0 to 323.5 for class 5), as well as reductions in 30-day readmissions (45.5 to 0 for class 5).
The researchers noted that although costs per-member per-month increased after the intervention, net savings in medical costs were calculated to be $276.80 for CKD class 3 and $480.79 for class 5.
They wrote that more-and-continued focus on CKD management strategies is currently needed, specifically referencing an electronic clinical quality measure for both commercial and federal quality improvement systems to better laboratory testing.
“The 2021 Medicare Advantage coverage for ESRD is on the horizon,” they concluded. “Commercial payer costs for advanced CKD and dialysis continue to escalate and absorb an increased amount of health care resources despite these patients representing a small proportion of the population. This study demonstrates that in a distributive primary care workspace, leveraging PCMH tools for CKD risk, the attention of clinicians can be captured for screening, identifying, prioritizing, and referring at-risk patients using this simple, scalable tool.” - by Melissa J. Webb
Disclosure: Vassalotti reports receiving consulting fees from Janssen, Inc.
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