Value-based care offers solutions for CKD management
Click Here to Manage Email Alerts
I reflect on my privilege frequently. I live in a safe home in a leafy neighborhood with my wife and two children. We have employer-funded benefits. Our family is generally equipped to meet life’s challenges.
It was not always this way. I grew up in a family that struggled with health issues and limited resources. Fear and uncertainty were common emotions. I gained perspective about the world and people around me.
What I learned then is that many families were living in some form of survival mode. What I know now is that the impact on health is profound, especially in rural areas and communities of color.
Unique opportunity
Fifteen years into my career as a health lawyer, it has become clear to me that health care leaders and their legal counsel have a unique opportunity and responsibility to confront barriers faced by patients. Health disparities are in plain view, new care models are being tested, financial incentives and revenue streams are evolving, and regulators have created new pathways to drive transformation and innovation. The paradigm shift occurring in the “kidney care industry” is a prominent example.
Kidney disease is a killer and it costs billions. Many are unaware of it until the disease is advanced or a threat to life itself. Every year, kidney disease is a top 10 leading cause of death in the U.S. The disease is more prevalent among Hispanic, Native American and Black people, which experience kidney failure at higher rates than white people. In recent decades, health care spending has focused on complications or late-stage treatments.
The science of modern dialysis is remarkable. It can sustain life, at least temporarily, but it is only available after the kidneys fail and the treatment itself has a significant impact on quality of life.
Kidney transplantation can be life changing. More than 25,000 kidney transplants occurred in 2022, a new record. Thousands of lives have been saved by this surgery. The challenge resides in unmet demand and systemic barriers to transplant access for historically excluded populations.
Our approach to kidney disease must be reimagined. The cost of care is significant, and outcomes are unacceptable. Early screening is not happening at scale. The timing of diagnosis is coming too late. The disease is progressing too fast. Patients with kidney failure are experiencing costly and traumatic hospitalizations. Care planning often fails to dignify patients with a robust set of options that consider the whole patient and their wishes (eg, palliative dialysis). And health disparities magnify the impact of kidney disease in vulnerable communities.
Value-based care
Strive Health estimates there is more than $400 billion of unmanaged kidney disease spend in the United States. What is promising is that an increasing percentage of that spending is being managed through value-based care (VBC) arrangements with payers.
VBC arrangements include a variety of financial models — per member per month fees, pay-for-performance, shared savings and global risk. There is considerable focus on diagnosed stage 4 and 5 chronic kidney disease and end-stage kidney disease, but little focus on diagnosed stage 1 through 3 CKD or undiagnosed CKD.
The centrality of nephrologists in VBC models is paramount. With the right financial incentives, supportive infrastructure and data-driven insights, nephrologists are ideally situated to improve health outcomes. The work involved is challenging, but the benefits of those efforts over time can be substantial.
For payers, VBC arrangements are gaining traction, particularly after the 21st Century Cures Act, passed by Congress in 2016, opened the door for patients with ESKD to enroll in Medicare Advantage plans. The prospect of lowering costs while improving patient satisfaction and outcomes is too appealing. Medicare Advantage plans are highly focused on VBC arrangements for patients with kidney disease. Interest among commercial plans is increasing and Medicaid plans will eventually follow suit in a greater number of states.
For patients, VBC arrangements provide patients with access to a specialized and interdisciplinary care team, tailored disease and dietary education and resources, which help mitigate real-world barriers. Mature VBC models screen for social determinants of health and use that information to support interventions and innovation. The investments that follow have the potential to mitigate social isolation, hunger/food insecurity, health-harming legal issues, limited English proficiency, transportation and other vexing health disparities.
Health equity
Since its inception in 2010, the CMS Innovation Center has been testing new payment and care models. There are currently more than 40 active programs. This work is driving a transition to value, particularly for patients with kidney disease.
In late 2021, the CMS Innovation Center renewed its strategic vision. Advancing health equity is prominently featured and the plan is to “embed health equity in every aspect of CMS Innovation Center models and increase focus on underserved populations.” There are many definitions of health equity, but the idea is simple: Health equity is a process that aims to identify and resolve health disparities experienced by different patient populations.
There was a clear shift in 2022, beginning with the redesign and launch of the Realizing Equity, Access, and Community Care Accountable Care Organization (Reach ACO) model. Reach ACO participants are now required to create a health equity plan and establish health equity data gathering and reporting. A similar shift is occurring in the Kidney Care Choices (KCC) model. This year, KCC model participants are also required to create a health equity plan and establish health equity data gathering and reporting. These activities are not yet tied to financial incentives as in the Reach ACO model, but the policy update suggests that such a change is on the horizon. It is promising that CMS is emphasizing health equity investment so prominently in program design.
Regulations support innovation
Several years ago, HHS launched its Regulatory Sprint to Coordinated Care and engaged in federal rulemaking aimed squarely at encouraging more VBC in health care. The regulatory environment has become more balanced and supportive as a result (see Table).
Harnessing these regulatory pathways has become a value driver, not for the sake of compliance itself, but to diminish the impact of real-world barriers facing patients. Great ideas with a bona fide connection to the VBC principles may be fully protected if properly structured.
These market developments are making health equity investment a business imperative in the context of kidney disease. It is also the right thing to do. What impacts health outside of traditional care settings is no longer the exclusive realm of government programs, nonprofits and philanthropy. Health care leaders and their counsel must prioritize investments that make it easier for patients with kidney disease to achieve their full health potential. Whether and how well those efforts improve outcomes and lower cost is something to watch closely in the next few years.
What is learned has the potential to inform transformation across the health care industry.
- References:
- Boyer G, et al. Health Affairs. 2022;doi:10.1377/forefront.20220116.500107.
- Braveman P, et al. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. Published May 1, 2017. Accessed Sept. 6, 2023.
- Carrell C, et al. https://www.americanhealthlaw.org/content-library/journal-health-law/article/db200f28-953c-4e1d-bbad-bb81cd4bb570/disparities-in-access-to-solid-organ-transplant-se. Published May 23, 2022. Accessed Sept. 6, 2023.
- CDC. https://www.cdc.gov/nchs/fastats/kidney-disease.htm. Published Jan. 9, 2020. Accessed Sept. 7, 2023.
- CDC. https://www.cdc.gov/kidneydisease/basics.html. Published Feb. 28, 2022. Accessed Sept. 7, 2023.
- CMS. (n.d.). Innovation Models. https://www.cms.gov/priorities/innovation/models#views=models. Published Nov. 8, 2021. Accessed Sept. 7, 2023.
- CMS Innovation Center Strategy Refresh At-a-Glance. https://innovation.cms.gov/media/document/strategic-direction-glance. Published March 30, 2023. Accessed Sept. 7, 2023.
- HHS. Social determinants of health. Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/priority-areas/social-determinants-health. Accessed Sept. 6, 2023.
- National Institute of Diabetes and Digestive and Kidney Diseases. Kidney Disease Statistics for the United States. https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease. Published Jan. 3, 2019. Accessed Sept. 6, 2023.
- Office of Inspector General, HHS. Fact sheet final rule: Revisions to the safe harbors under the anti-kickback statute and civil monetary penalty rules regarding beneficiary inducements. https://oig.hhs.gov/documents/compliance/836/factsheet-rule-beneficiary-inducements.pdf. Published November 2020. Accessed Sept. 7, 2023.
- Office of Inspector General (OIG), HHS. Safe harbor regulations. https://oig.hhs.gov/compliance/safe-harbor-regulations/. Published Oct. 20, 2021. Accessed Sept. 7, 2023.
- Shorter T, et al. https://www.americanhealthlaw.org/content-library/journal-health-law/article/ff37bcdd-451a-41d2-bdc5-5e3f3daad14a/we-have-met-the-enemy-and-he-is-us. Published May 23, 2022. Accessed Sept. 6, 2023.
- Young, C. 2022 organ transplants again set annual records. https://unos.org/news/2022-organ-transplants-again-set-annual-records/. Published Jan. 10, 2023. Accessed Sept. 7, 2023.
- For more information:
- Larry Lanham is deputy general counsel at Strive Health. He can be reached at llanham@strivehealth.com.
Collapse
Read more about
Click Here to Manage Email Alerts