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March 13, 2023
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Like a good neighbor, a nephrologist is there to treat patients

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We are more than 1 year into the Medicare Kidney Care Choices model directed at patients with chronic kidney disease stages 4-5 and with end-stage kidney disease, a true test of value-based medicine.

Nephrologists are convening in New Orleans at the Renal Physicians Association Annual Meeting in March to learn the impact of value-based care on their practices and strategize for the year ahead. It provides an opportunity to reflect on our respective roles in the broader complexity of our health care delivery system.

Dating back to 2010, when the American College of Physicians released its policy paper, “The patient-centered medical home neighbor: The interface of the patient-centered medical home with specialty/subspecialty practices,” and the High Value Care Coordination Toolkit in 2014, the optimal timing and methods of referring patients for CKD care remain more important than ever when working within this new paradigm.

Keith A. Bellovich

Repeatedly, when I find myself engaged in conversation with colleagues, CMS administrators and legislators on Capitol Hill, it is helpful to remember that health care providers did not create this system; we are merely required to work within its confines and continually focus on optimizing care on the behalf of patients.

Complexities of care

In the interest of being good neighbors, nephrologists stand ready and willing to devote their lives and careers to the prevention of kidney disease. Running an ambulatory practice for patients with a chronic illness is an expensive endeavor, with more staff time required to manage complex patients. Designing care plans, reviewing numerous medications and carefully delivering detailed education about a patient’s destiny requires a skilled and competent team.

Private practice nephrologists are active members within their community who are small business owners. Practices employ numerous staff who are in short supply and committed to the health of the local community. A limited 1% increase in fee-for-service payments for practicing nephrologists projected for 2023, coupled with additional cuts to the conversion factor and elevated inflationary costs to the operation of a clinical practice, poses significant challenges to continue delivering this intricate care to patients.

Mental health

There is some good news. Results from the Physician Burnout and Depression Report 2023 showed that nephrologists had lower scores for burnout than many other subspecialities. The report was based on a 2022 poll of 9,100 physicians in which 53% of respondents reported burnout, up from 47% in 2021. Nearly 25% of physicians also reported being depressed in 2022, according to the survey.

As a specialty, 44% of nephrologists said in the survey they feel burned out. This ranked nephrology 16th overall, between orthopedics and cardiology. I tend to find that my colleagues are relatively satisfied in their practices. In the same pool, primary care/internal medicine specialists, one of our key referral sources, ranked the second highest for feeling burnout.

Are nephrologists really that satisfied and fulfilled? Certainly, our workforce has been challenged like never before as we emerge from the pandemic years. We also face an ongoing downturn of medicine residents applying for nephrology fellowships. Add in further subspecialization within the profession of nephrology, such as interventional nephrology, critical care and onco-nephrology, and we continue to place further limitations on that workforce to reach an expanding population of patients with high rates of kidney disease. We now possess tools where we can make a difference if provided the opportunity and are able to identify the right populations.

Patient referral

It becomes important to analyze the timing and methods of referrals of patients with varying stages of CKD into our practices. We cannot afford to be wasteful or inefficient in applying this expertise to the patients who need it most, and it becomes critical to insure we have all the information we need before the visit to educate our patients with a solid and effective therapeutic plan. Are we cost-effective in requesting diagnostic data before the visit? Did we close the loop with a clear plan articulated to the patient and family, but also to the referring physician for future reference? These questions are essential in that analysis to ensure our limited workforce is being utilized to its fullest.

We know disparities exist in underserved populations that are overrepresented within our at-risk populations. Are we serving these neighborhoods as effectively as possible? The specialty of nephrology is embracing value-based care in a big way. Can we make a difference in the outcome and quality of kidney care and do it for less?

Make a difference

While we test these theoretical advancements that earlier referral is better, apply more sophisticated screening tools for at-risk populations, prioritize care for the right individuals, invest in education about disease prevention and apply our advances in therapeutics, we are eager to know if we can truly make a difference. Our self-interest will lead to further explorations into these questions, but we will also see a broader application of principles from value-based care options offered in Comprehensive Kidney Care Contracting, a set of three voluntary payment options under the Kidney Care Choices model. We are also seeing the additional investment of public and private equity into the organizations that are participating in this demonstration. We are eager to know these outcomes.

Organizations like the RPA believe strongly that this creative approach to innovation does not limit capabilities to merely Medicare-eligible stage 4 patients with CKD. It is a first step toward a broader strategy to improve the lives of all patients with kidney disease regardless of stage or payer. If we do not succeed, we will continue to increase preemptive transplantation and, while respecting patient autonomy, provide dialysis modality selection directed toward home-based therapies where possible because nephrolgists believe those are the best approaches to helping patients cope with kidney disease.

It is this enthusiasm and excitement that provides a ray of hope and opportunity toward continued true professional fulfillment as an expert in the specialty of nephrology and the ultimate prevention of kidney disease. I am glad I am part of it.

Like a good patient-centered medical home neighbor, nephrology is there.