Beyond hospitalizations, value-based care can impact early CKD, transplant outcomes
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In value-based care, the term “follow the money” may be fitting to define the goal of payers providing care for patients with chronic kidney disease, kidney specialists said, because it is tied to a key outcome – hospitalizations.
“Starting at the later stages of CKD and [end-stage kidney disease] ESKD management was an obvious first step [in value-based care] because there is such a huge cost there,” George M. Hart, MD, chief medical officer for Interwell Health, told Healio | Nephrology News & Issues. “It is our ability to offer specific interventions that provide an immediate ‘bang for your buck,’ if you will — not only in improving the patient journey and outcomes but bringing a return on investment that everyone felt was needed,” Hart said.
Photo courtesy of Interwell Health
Even before HHS launched the Advancing American Kidney Health initiative in 2019, CMS and its Innovation Center (CMMI) have pushed for improvements in managing patients with kidney disease who often have little to no pre-dialysis care.
“In the United States, one-third of incident ESKD patients have received little or no pre-ESKD care,” M. Yahya Jan, MD, and Jay B. Wish, MD, from the department of medicine, division of nephrology at Indiana University School of Medicine, wrote in a commentary in Kidney International Reports. “Only 60% of incident long-term dialysis patients in the United States have been seen by a nephrologist for longer than 6 months prior to dialysis initiation ... Late or lack of referral to a nephrologist is associated with poorer patient outcomes and increased costs after dialysis initiation,” they wrote.
Cost of CKD
Those late referrals for patients with advanced CKD are costly to Medicare and commercial health plans. According to the latest data from the U.S. Renal Data System (USRDS), expenditures for hospitalizations increased by approximately 24% from 2011 to 2019 — from $20.6 billion to $25.5 billion — before decreasing to $23.9 billion in 2021.
Costs for infection-related hospitalizations increased by nearly 30%, from $4.8 billion in 2019 to $6.2 billion in 2020, and remained at $5.7 billion in 2021, according to the USRDS.
While payers are focused on reducing hospitalizations for patients in CKD stages 4 and 5, Robert Gluckman, MD, former chief medical officer for Providence Health Plan, told Healio | Nephrology News & Issues that identifying patients earlier could be an option moving forward. Providence signed an agreement with Interwell in March 2023 to manage patients with advanced CKD under the health plan.
“Overall, the opportunity to improve care and patient outcomes with a wraparound care approach is what drove this partnership with Interwell Health,” Gluckman said. “In addition to reducing total cost of care, we have targets to reduce emergent initiation of dialysis, increase adoption of home dialysis, identify appropriate transplant candidates and reduce emergency room and hospital admission.
“We do see value in earlier interventions, which is why we include [CKD] stage 3b patients in this program as well,” he said.
“The hope, and I think all of us who are in health care and in this space agree, is that by pivoting and going further upstream, we have the ability to have interventions that will bear fruit,” Hart said. “Patients can stay in the earlier stages of CKD for a long time, so you need payers that take a long view.
“I think that’s the beauty of the CMMI models where patients can potentially be enrolled in earlier stages and continue through the continuum of their care,” Hart said. “We’re finding some of the Medicare Advantage payers have a similar interest because patients are staying longer in these programs and there is more of an interest and willingness to make an investment up front to try and stave off some of the higher costs further down the road.”
Moving forward with a value-based care model is important to nephrologists, but change can be challenging, Keith Bellovich, DO, president of the Renal Physicians Association, told Healio | Nephrology News & Issues.
“The future of health care is the value-based care arrangement,” Bellovich, chief medical officer and chief of the division of nephrology at Ascension St. John Hospital in Detroit, said. “Yet for nephrologists to turn their back on the [monthly capitated payment] MCP, which is the lifeblood of nephrology practice ... and allows the nephrologist to sustain independence” is difficult, Bellovich said.
Transplant care
Value-based care also can be a useful tool in managing patients interested in a kidney transplant, according to authors of a study published in Kidney International Reports. The researchers proposed a model that would offer more “ambitious transplant-access focused targets,” Benjamin E. Hippen, MD, senior vice president and head of transplant medicine and emerging capabilities at the Global Medical Office of Fresenius Medical Care, and colleagues wrote. “As the challenges of ‘siloed’ care for patients with CKD, ESKD and kidney transplants is a global challenge, a successful end-to-end payment model in the United States may be useful to clinicians and health systems globally.”
The transplant-inclusive value-based care (TIVBC) model would also tackle a controversial issue in organ allocation: the number of donated kidneys discarded by transplant centers that are deemed unsuitable for surgery. According to the Association for Organ Procurement Organizations, the rate of organ non-utilization in the United States for kidneys increased to 28% in 2023.
“Current regulatory and financial incentives for transplant centers make it easier to discard than to accept organs offered for transplantation,” Hippen and colleagues wrote. “Any TIVBC model should align incentives which favor more aggressive acceptance of higher-risk organs and recipients, with the clear understanding that this change is likely to come at the expense of observed and expected patient and graft survival.”
Moving forward
Hart said fundamentally the CMS payment models have the right components to make value-based care a success, although the infrastructure costs to participate can be difficult for nephrology practices.
“I love the fact that the attribution is through the nephrology practice and not the dialysis provider. I love the fact that it includes CKD, ESKD and transplant patients,” Hart said. “I do think we need improved stability in the understanding of the payment model, so that we as nephrologists and we as value-based care companies can have confidence as to what the financial benchmarks are going to be.
“And in value-based care, the savings that come are sometimes 2 or 3 years after you’ve been involved. So once again, investing in infrastructure with a horizon that you’re only getting returned 2 years later, 3 years later, is hard for nephrologists and can be hard for value-based care companies if they don’t have deep enough resources.
“We’re still early in this journey,” Hart said. “But I do think the foundations of how we’re going about this are strong and run deep.” – by Mark E. Neumann
- References:
- Hippen BE, et al. Kid Intl Rpts. 2023;doi:10.1016/j.ekir.2024.02.004.
- https://www.healio.com/news/nephrology/20240124/us-organ-procurement-organizations-recovered-more-than-43000-organs-in-2023. Published Jan. 24, 2024. Accessed Feb. 20, 2024.
- Jan MY, et al. Kidney Int Rep. 2020;doi:10.1016/j.ekir.2020.11.014.
- United States Renal Data System. USRDS Annual Data Report: Epidemiology of kidney care in the United States. NIH, National Institute of Diabetes and Digestive and Kidney Diseases. https://usrds-adr.niddk.nih.gov/2023/chronic-kidney-disease/6-healthcare-expenditures-for-persons-with-ckd. Bethesda, Md., 2023. Accessed Feb. 20, 2024.
- For more information:
- Keith Bellovich, DO, can be reached at kbellovich@scsp.net.
- George M. Hart, MD, can be reached at ghart@interwellhealth.com.
- Benjamin E. Hippen, MD, can be reached at benjamin.hippen@freseniusmedicalcare.com.
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