Payers, providers see value-based care as opportunity to treat early stages of CKD
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One goal of the Advancing American Kidney Health initiative, which was launched in 2019, was to significantly increase the number of kidney transplants.
The way to do that, according to CMS at the time, was to intervene early and slow chronic kidney disease progression so preemptive transplants could be performed, allowing patients to forgo dialysis.
Source: Chris Peters
“ ... [A] healthier, well-managed patient with CKD can have an orderly transition into end-stage kidney disease if that ultimately happens, but ideally, value-based care can focus on slowing the progression of disease and help the team [plan for] a preemptive transplant,” Carmen A. Peralta, MD, MAS, FASN, chief clinical officer for Interwell Health, told Healio | Nephrology News & Issues.
Interwell is one of a number of companies (see Table) that offers Medicare and commercial health plans a package of treatment services for patients with advanced CKD.
Interwell treats more than 100,000 patients with late-stage CKD and ESKD through its 1,600-plus provider network.
Robert Gluckman, MD, chief medical officer for Providence Health Plan, understands how value-based care can help control health plan costs for patients with advanced CKD. Providence recently signed a contract with Interwell to manage beneficiaries with CKD in stages 3b, 4 and 5.
“Overall, the opportunity to improve care and patient outcomes with a wraparound care approach is what drove this partnership with Interwell Health,” Gluckman told Healio | Nephrology News & Issues. We do see values in earlier interventions which is why we include Stage 3b patients in this program as well.”
He added: “The health and wellbeing of members is our topmost priority. That, along with our mission to serve all especially the poor and vulnerable made this population a high priority for us.”
Support of payers
Before joining Interwell, Peralta was a professor of medicine at the University of California San Francisco, where she established the Kidney Health Research Collaborative, an organization dedicated to the early detection and management of CKD and its complications.
“My entire life’s work has been around early detection, risk stratification, caring for people at high risk and early CKD management,” she said.
Peralta said clinicians like Gluckman at Providence and at other health care plans are now seeing the burden that patients with CKD place on the health care system and are looking for ways to provide better disease management.
“I think that commercial payers have a better understanding now about the benefit of identifying and treating these patients earlier from a cost perspective. We are beginning to see more payers transition to value-based care, especially in the kidney space, given the huge cost,” Peralta said.
“Of course, CMS has led this effort, but payers have followed suit.”
CMS demonstrations
As a federal agency regulating payments to nephrologists, dialysis providers and hospitals, CMS has launched a number of demonstrations during the last decade in its efforts to exit the fee-for-service payment structure and develop a more wholistic approach to patient care that saves money.
The effort has a direct connection with the cost to Medicare to treat patients with ESKD. In 2019, close to 800,000 patients were living with kidney disease, according to data from the U.S. Renal Data System. Seventy-one percent of those patients were on dialysis and 29% had a kidney transplant. The cost for kidney care was $37.3 billion in 2019, absorbing 7% of the Medicare budget while representing 1% of Medicare beneficiaries.
CMS took the first step in 2011 to rein in costs by creating the Prospective Payment System (PPS) for dialysis providers. The PPS created a payment that bundles all treatment costs, including lab tests and most drugs.
Value-based care models go a step further by putting entities in charge of treatment costs, physician payment and offering incentives to reduce costly hospitalizations and directing patients into more efficient treatment options. In the case of kidney disease, this is either home dialysis or a kidney transplant. Previous CMS demonstrations have focused on patients with ESKD who were already on dialysis. However, the Kidney Care Choices (KCC) demonstration focuses on pre-dialysis care and currently has more than 200 entities in its second year of operation.
DaVita integrated Kidney Care provides CKD and ESKD care to 82,000 patients in value-based care agreements and has 22 entities in the KCC demonstration. “KCC aligns incentives to drive quality of care, which will lead to a reduction in overall costs and a savings for the system,” David Roer, MD, FACP, FAHA, FASN, vice president for medical affairs, told Healio | Nephrology News & Issues. “But the idea of ‘value’ is two-fold. Yes, there is the value from a financial standpoint, but the real benefit comes from the value it provides patients by keeping them safe, healthy and out of the hospital. It’s about moving care from reactive to proactive and spurring relationships between patient and provider that are relational vs. transactional.”
Alex M. Azar II, former Secretary to HHS and author of the Advancing American Kidney Health initiative, said the KCC demonstration was long overdue.
“We went 5 decades before we initiated major CKD/ESKD reform,” Azar said in an interview with Healio | Nephrology News & Issues earlier this year. “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,” he said. “Value-based care will create the partnership that we need between the provider and the patient on slowing CKD progression,” Azar said.
Outcomes
During a panel discussion at the Renal Physicians Association Annual Meeting in March, speakers presented ways physician practices and value-based care companies can collaborate on care models.
“Value-based care is here to stay within the nephrology specialty, so it’s something that all physicians are going to have to deal with ... regardless of the size of their practice,” David Arrieta, MBA, CMPE, SHRM-SCP, who chaired the panel,told Healio | Nephrology News & Issues. “The second component that I think came through in the panel [discussion] is that value-based care takes time, and it takes momentum.”
Researchers at Strive Health recently completed a year-long study of 350 patients to see if interventions were slowing the progression of kidney disease. Strive helps manage more than 80,000 patients with advanced CKD in 30 states, according to a company press release.
The study measured the change in eGFR of Strive patients with CKD compared with a control group of patients who were not enrolled in Strive’s program but were matched by propensity scoring for clinical factors and were in stage 4 or 5 CKD.
“We used a host of data points to stratify our patients from highest to lowest risk,” Amit Kapoor, MD, chief nephrologist for Strive Health told Healio | Nephrology News & Issues. “We identified the risk profile and the cost of utilization tied to that, and then we deployed our interventions specific to the clinical and non-clinical needs of our patients in that risk profile.”
Patients in the study had eGFRs ranging from less than 15 mL/min/1.73 m2 to less than 60 mL/min/1.73 m2.
In the study, 3.2% of the Strive patients reached a significant decline in kidney function after 12 months. In comparison, more than double in the baseline group had a major decline, according to the release.
“The study indicates that the Strive Health care model delays late-stage CKD progression,” according to the release. “When kidney function declines rapidly, patients are at higher risk to progress to ESKD, which typically leads to higher health care costs.”
Expanding treatment
Roer and Kapoor said being able to address CKD at earlier stages could benefit more patients.
“The earlier we can intervene, the better it is for the patient,” Kapoor said. “At every stage, our patients get worse. Cardiovascular risks increase exponentially.
“Once you get to stage 4, there is a higher likelihood you will progress to 5,” Kapoor said.
“For patients in stage 4 or 5, there’s still a great opportunity to impact their care by managing comorbidities and using evidence-based guidelines to slow the progression of kidney disease,” Roer said. “That said, we certainly see benefit to moving even further upstream, including with proteinuric renal disease.”
But many patients are seen on first visits who are near kidney failure and have yet to see a nephrologist, Peralta said.
“What we find when we look at a new contract with a health plan is that many patients have never seen a nephrologist,” Peralta said. “These are patients in stage 5 CKD. They don’t have plans for a [vascular] access.
“These are patients that need attention.”
- References:
- Chen J, et al. Study demonstrates that patients in value-based care models are less likely to experience significant declines in kidney function. https://strivehealth.com/news/study-demonstrates-that-patients-in-value-based-care-models-are-less-likely-to-experience-significant-declines-in-kidney-function. Accessed June 21, 2023.
- End-Stage Renal Disease. United States Renal Data System Annual Report. 2020. https://usrds-adr.niddk.nih.gov/2020/end-stage-renal-disease. Accessed June 21, 2023.
- www.healio.com/news/nephrology/20230410/video-valuebased-care-requires-time-investment-to-be-successful
- For more information:
- Amit Kapoor, MD, can be reached at akapoor@strivehealth.com.
- Carmen A. Peralta, MD, MAS, FASN, can be reached at carmen.peralta@ interwellhealth.com.
- David Roer, MD, FACP, FAHA, FASN, can be reached at david.roer@davita.com.
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