Former HHS chief says ‘no turning back’ on value-based care for ESKD
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Editor’s note: As part of the focus this month on reimagination of the End-Stage Renal Disease Program, Healio/Nephrology News & Issues interviewed Alex M. Azar II, who served as the HHS Secretary from 2018 to 2021. During that time, the agency launched Advancing American Kidney Health (AAKH), an initiative that set new goals for patient treatment, created KidneyX to help companies develop new products, and launched new demonstrations and care models aimed at increasing home dialysis, transplantation and treating chronic kidney disease at earlier stages.
Azar had a personal connection with the AAKH; his father, a prominent eye surgeon who was also an adjunct instructor at Johns Hopkins’ Wilmer Eye Clinic, experienced both in-center and peritoneal dialysis for treatment of end-stage kidney disease before getting a kidney transplant in 2014.
Prior to serving as HHS Secretary, Azar served as president of the U.S. affiliate of Eli Lilly and Company and was deputy secretary and general counsel for HHS under the George W. Bush administration.
Azar is a member of the board of directors for Interwell Health, a kidney disease management company that partners with physicians focused on value-based care.
Healio/Nephrology News & Issues: Although leadership at HHS has changed in Washington, D.C., the AAKH and its goals have had staying power. Are you surprised?
Alex Azar: So many of the things that I tried to do while HHS Secretary – like the AAKH – were the continuation of a journey. The AAKH was about value-based care, and we wanted to move that forward. And the initiative was bipartisan.
Healio/Nephrology News & Issues: You said your father’s experience with kidney failure – and his experience with PD – was a motivating factor in developing the AAKH initiative.
Azar: PD was transformative. Having dialysis at night and reaching a steady energy and activity level compared to the draining experience with in-center hemodialysis was a big difference.
Healio/Nephrology News & Issues: How would you rate the modality options education your father received?
Azar: My father was well educated, and I was Deputy Secretary of HHS and president of Eli Lilly. Yet it took almost a year and a half for us to get the kind of health-based education on modality alternatives, like on PD and the difference it could make. I think that highlights how important early patient education is in CKD progression.
Healio/Nephrology News & Issues: What were the other factors that helped motivate you to gain support for AAKH?
Azar: Certainly, an important issue was that $1 out of every $5 spent in the Medicare program was going to the treatment of conditions related to kidney disease. If you want to put Medicare on a more solid footing, you have to address the cost of dialysis and transplantation.
I also viewed one of my central missions to be the final Secretary to say, “We are not going backward to procedure-based fee-for-service.”
If you could fix the payment system, whether it was for nephrologists or primary care, the key is becoming a partner with the patient in delivering better outcomes – keeping patients out of the hospital, keeping them out of center-based dialysis, slowing the progression of kidney disease, slowing heart disease and slowing diabetes. Those were our goals with AAKH.
From my view, projects that focus on capitated payments, or total cost of care, whether it is in primary care projects, oncology demonstrations or the kidney care initiative, enable doctors to practice medicine the way they wanted in medical school – empowered, not micromanaged from above.
Healio/Nephrology News & Issues: Do you still believe the AAKH goals are realistic?
Azar: If you want to motivate a team, you need to have goals that are transformational and inspirational. If you set goals that you know can be achieved, you are doing nothing. I think the AAKH goals are stretch goals, but they are all realistic, and the primary care/nephrology world is motivated to achieve them.
Healio/Nephrology News & Issues: Financial incentives are frowned upon in health care because physicians do not think incentives influence practice patterns. What is your view?
Azar: The fee-for-service model has shown that when you pay for more procedures, you will get more procedures.
If you fail to recognize that health care goods and services are economic goods and services and operate according to economic laws, you will always be disappointed and surprised. That is why central to ESRD Treatment Choices and Kidney Care Choices (KCC) models is changing the incentive structure from current payment models. If you want more transplantation, pay more for transplantation. If you want a reduction in CKD progression, reward reduction in CKD progression. These approaches help providers do well by doing good.
Healio/Nephrology News & Issues: The KCC model is really the first to tackle advanced CKD. Should we have paid attention to this patient group sooner?
Azar: Absolutely. We went 5 decades before we initiated major CKD/ESKD reform. With value-based payment and total cost of care, we had to learn how to walk before we could run. We had to learn about bundled payments; what goes into a bundle. But now, with all the new drugs available for slowing CKD progression and the interest in better nutrition and the benefits of exercise, the timing is right for us to be involved with the KCC model. We think we can have a meaningful impact on stage CKD 4 to 5 progression.
Healio/Nephrology News & Issues: All these changes will come about under the value-based care model. What do you think are the important pieces that a value-based company needs to be successful?
Azar: There is no question that value-based care is the right path. We have 80% of our patients going to in-center dialysis. We have one of five patients who die each year waiting for a transplant. The current system is not working.
Value-based care will create the partnership that we need between the provider and the patient on slowing CKD progression. If it has to be dialysis, it should be home-based dialysis – and getting a transplant as quickly as possible. And we will have the financial incentives to drive that practice change. There is no turning back. I don’t see any alternative.
Healio/Nephrology News & Issues: Will there be room in this partnership for independent nephrologists or do they have to join a large practice to remain viable?
Azar: You do need sophistication. You need high-end analytics, a good electronic medical records system and a partnership with dialysis providers.
We need to have tools to help small practice integrate into value-based care. My dad was an independent physician; everything I have done is aimed at allowing independent physicians to remain independent. There are enablers out there to help them do that and be part of value-based care. Interwell has those foundational elements, and it can leverage those decades of experience with treating kidney disease. Likewise, being in partnership with the doctors is a key benefit.
Healio/Nephrology News & Issues: If we were to ‘reimagine’ the AAKH initiative – the targets, the incentives and performance goals – would you do anything differently?
Azar: No, but you have to take providers where they are, which is why we have different models in the KCC demonstration. And key to the success is the government’s commitment. Medicare must be a steady business partner. It must be predictable, transparent and reliable.
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