Integrated Nephrology Care: What Does the Future Hold?

Care of the patient with end-stage renal disease (ESRD) is complicated and expensive. Implementation of an integrated care model in nephrology has been shown to improve efficiency in recently completed Centers for Medicare & Medicaid Services (CMS) Demonstrations project.  Author of a recent article in American Journal of Kidney Diseases, Dr. Allen Nissenson (AN) was part of the design and implementation of this project. He also is an expert on Accountable Care Organizations (ACOs), a system for improving cost and quality of health care. Dr. Nissenson discusses his article, the demonstration project, and ACOs with Dr. Joel Topf (eAJKD), eAJKD advisory board member.

eAJKD: Can you describe renal care in the  general ACO setting?

AN: Since the general ACOs really haven’t started, it is hard to know how renal care will be organized.  We have experience in this area, delivering kidney disease management through VillageHealth, the DaVita integrated care management organization. VillageHealth is comprised of a dedicated team of trained nurses and professionals providing integrated care management to patients with kidney disease throughout the United States. The intention is to provide services to help improve the lives of our patients by preventing complications, reducing the number of avoidable hospitalizations, and improving overall health while constraining the overall costs of care. Very few of the general ACOs are currently equipped to focus on kidney patients. I feel that once the general ACOs start, patients with ESRD may be ignored or poorly managed as they are in the current fee-for-service system.

eAJKD: The quality markers are central to the success of the ACO model. Do these quality markers in general ACOs address renal care?

AN: There are two sides to the quality metrics question.  First, there remains considerable disagreement in the renal community on the most impactful quality indicators for our patients. The 33 quality metrics required as a part of the generic ACO do not include those that there is at least some agreement among nephrologists would be important.  More importantly among those 33 some would not be appropriate for kidney patients. For example, depending on the age of the patients and the extent of co-morbidities, it may be appropriate to not do a cancer screening. As recently noted in the Choosing Wisely project by the American Board of Internal Medicine, one of the things mentioned for nephrology care was to not perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms unless they are transplant candidates. This includes mammography, colonoscopy, prostate-specific antigen testing, and pap smears. It is neither cost-effective nor does it improve survival. Nephrologists involved in ACOs should be assured that the actual quality metrics used are relevant to our population, and exclude those that are either irrelevant or could even cause unexpected consequences when applied for our patient population.

eAJKD: What is the ESRD DM Demonstration Project? How did they measure cost savings?

AN: The ESRD DM Demonstration Project was a 5 year demonstration project (2006 to 2010) conducted by CMS to test the impact of expanded integrated care approaches applied to the Medicare ESRD patient population. The first 3 years of the Demonstration (2006 through 2008) were evaluated under this project . The analyses were independently performed by the Arbor Research Collaborative for Health (the CMS Evaluation Contractor). The project included DaVita, Fresenius, and a third participant with very few patients. A control group was used. Fresenius operated in several different sites around the country, and the DaVita Demo was done in one site in Southern California. Control groups similar in terms of the geographic distribution were used. The control group and the intervention group for each company were matched using propensity scoring to try and eliminate any confounders.

eAJKD: There was a decrease in hospitalization and a decrease in mortality. Can you comment on those impressive findings?

AN: The overall demo showed decreased mortality, decreased hospitalizations, and decreased costs as the three primary outcomes. Individual secondary focuses, such as minimizing fluid overload, providing nutritional supplements, aggressively focusing on catheter removal, and implementing medication therapy management, were used by one company or the other and all proved effective. As we move forward, we want to look at the combined experience of the two programs and evaluate many specific interventions, whether it’s vascular access, fluid management, nutrition, or medication therapy management. As we combine these outcomes, a robust program can be developed that will require the coordination of care that can only be achieved in an ACO setting. The Fresenius data can be found on their website (full evaluation report).  A summary of the results from both companies was recently published in Nephrology News and Issues.

eAJKD: If you were a nephrologist in one of these coordinated care portals, how would your dialysis experience be different?

AN: First of all, there would be an enhanced team of experts. In DaVita’s model we included nurse practitioners, pharmacists, and case managers.  Immediately, you would note the extra resources. These team members coordinate services, make sure patients go to appointments, and obtain the results of the appointments. They also ensure excellent communication between inpatient and outpatient setting. They focus on the transition points, particularly when the patients are discharged from the hospital. The improvement in transition of care is very important for many involved in health care, and national associations such as the National Transitions of Care Coalition are advocating efforts in this arena.  The electronic medical records will also make things much easier for transition of care. It will try to provide integration of what tends to occur in lots of different settings from lots of different providers.

Dr. Nissenson has a blog that focuses on nephrology issues, which has posts on current events as well as personal stories from his experiences in health care.

To view the article abstract or full-text (freely available), please visit; see also a freely available editorial on ACOs.

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