Driving Earlier, Better CKD Care Through a Patient-focused Payment Model

The National Kidney Foundation (NKF), in partnership with Northwell Health, is working to establish an alternative payment model to align incentives with better outcomes for patients with chronic kidney disease (CKD) stages 3-5 and to lower government expenses.  To inform this work, the NKF and Northwell hosted a roundtable on March 31, 2016 with leaders representing dialysis organizations, integrated healthcare organizations, and nephrology practices.  They discussed programs in early CKD care and how a payment model could facilitate improvements on a larger geographic scale.

Despite clinical practice guidelines and Medicare coverage of some early CKD care benefits, gaps in delivering optimal care for those with CKD stages 3-5 who are not on renal replacement therapy (RRT) still exist. CKD is underdiagnosed in its earlier stages; only 10% of patients are aware they have the condition. This leaves little opportunity for early intervention to reduce comorbidities, deliver patient education, and facilitate self-management and shared decision making.  The high presence of comorbidities, increased rate of hospitalizations, and improper care transitions results in nearly $100 billion in Medicare spending for patients with end-stage renal disease (ESRD) and earlier stages of CKD. While the cost of care for ESRD patients has received a great deal of attention, the aggregate costs for patients not on RRT are much higher: in 2013, Medicare spent $68 billion.* Thus, earlier CKD care positively impacts the Triple Aim: improved patient experience, better outcomes, and smarter spending.

The NKF has been leading the charge to increase early detection and improve care for CKD patients through its CKD Intercept initiative, which provides the knowledge and tools to alter CKD outcomes. Northwell Health’s Healthy Transitions program delivers patient-centered care and improves outcomes for patients with CKD stages 4 and 5.  However, payment is a key factor in the quality of healthcare delivered.  Misaligned payments can drive well-intended practitioners to focus on the tasks and treatments that net the greatest revenue, letting important tasks like coordinating patient care among healthcare providers fall by the wayside.

However, the landscape of health care payment is changing. Payments are moving away from fee-for-service and toward payment for value and outcomes, with payment to manage the health of populations as the ultimate goal. The U.S. Department of Health and Human Services (HHS) has set a goal to have 50% of Medicare payments tied to alternative payment models (APMs) by 2018. On April 28, 2016, the Centers for Medicare & Medicaid Services (CMS) released its proposal to implement qualifying criteria for the types of APMs in which eligible clinicians can participate to receive a 5% bonus payment and be exempt from the reporting requirements under the new Merit-Based Incentive Payment System. This changing landscape provides the opportunity to design a payment model that supports improved primary care and nephrology collaboration for delivering earlier and better CKD care. Such a payment model could also change the paradigm from late diagnosis, high mortality, and emergent start dialysis to the prevention of comorbidities and adverse outcomes, slowed progression, and eased care transitions.

Now is the time for the kidney community, and nephrologists in particular, to embrace a new model of care. The roundtable participants discussed challenges in developing and attaining practitioner participation in APMs for earlier CKD care.  Issues that must be discussed include the dialysis-centric nature of ESRD care; that payment for caring for dialysis patients yields greater profits to nephrologists and organizations than delivering earlier CKD care; that early CKD care is often time consuming; and that dialysis organizations have extended their contacts to patients with earlier CKD for management and education services.

Roundtable participants also discussed how a payment model could be aligned to create greater accountability and encourage others to improve earlier CKD care. They agreed that to achieve these aims, payment must 1) result in a return on investment; 2) be valued compared to a baseline cost of care and expected savings in spending; 3) be flexible to allow for new innovations in preserving kidney function and improving patient outcomes; 4) facilitate collaboration with the patient’s other healthcare providers; 5) emphasize early detection, diagnosis, and appropriate, timely referral by primary care practitioners; and 6) be patient centered with active patient involvement and opportunities for shared-decision making in alignment with patient’s personal goals, values, and preferences.

The NKF and Northwell Health will leverage lessons learned from this initial roundtable and continue leading the charge to develop an alternative payment model that aligns payments with better CKD care prior to ESRD.  We will establish a national workgroup of interdisciplinary healthcare professionals and patients to define a patient-focused payment model that can be tested by CMS and other payers.

Jeffrey Berns, MD
1President, National Kidney Foundation
2Associate Dean for Graduate Medical Education, University of Pennsylvania School of Medicine
3Nephrology Fellowship Program Director, University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Steven Fishbane, MD
1Chief, Division of Kidney Diseases and Hypertension Department of Medicine, Northwell Health
2Vice President for Network Dialysis Services, Northwell Health
3Professor of Medicine, Hofstra Northwell School of Medicine
Great Neck, New York

*Calculated from Table K of Volume 1 using total Medicare population, including patients under age 65.

2 Comments on Driving Earlier, Better CKD Care Through a Patient-focused Payment Model

  1. One of the things that would help early CKD patients is the availability of dietitian services. Unless you are also diagnosed with diabetes, dietitian services are not covered by insurance. Also, most of the the dietitians, if they are even available, have no knowledge of pre-diabetes, CKD diets. I finally was able to see one when I was diagnosed with both pre-diabetes and my GFR fell to 13. Before that, nothing was available, and when I did see her, she was clueless about CKD. Huge gap there for those of us trying to keep off of dialysis as long as possible.

  2. Gary Peterson // July 26, 2016 at 5:05 am // Reply

    This will do little to change US dialysis care. There will still be no incentive for increasing patient employment and rehabilitation, nor will there be any incentive to drive changes in dialysis technology or infrastructure.

    Until there is well-dialysis-patient statistical reporting and a substantial financial incentive for increasing employment rates, we are unlikely to see major improvements in patients’ lives, technology, system infrastructure, or societal lost opportunity costs. Unfortunately, the business focus of the largest for-profit provider has been to drive out the competition by providing minimalist, standardized dialysis care utilizing their forty-year-old technology. They are unlikely to embrace changes that will damage their business model and also give opportunities for other providers to further surpass them in terms of providing positive patient outcomes.

    US nephrology is still a long way away from having an effective understanding of the harmful effects of the financial incentives in its dialysis care system. More than any other medical specialty, US nephrology has tied its practice of medical to junk-bond financiers, resulting in a system of care that nephrologists would avoid for themselves and their own family members. Like chiropractors and naturopaths, too many US nephrologists fool themselves into believing they are doing the right thing… and take the easy money.

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