Value-based care for chronic kidney disease
Chronic kidney disease (CKD) affects 37 million Americans, and 90 percent don’t even realize they have it. In 2016, more than 725,000 Americans were on dialysis or living with a kidney transplant. With a cost of $72,000 per year for the average three times a week dialysis, end-stage kidney disease (ESKD) is a huge drain on the healthcare economy, representing 7 percent of the Medicare budget.
Beyond that, most dialysis patients have to stop working, amplifying the economic impact. With Medicare/Medicaid coverage and reimbursement focused on end-stage care, dialysis and kidney transplantation, there has been little systemic incentive to focus on preventive care for CKD.
But a number of nephrologists and value-based care experts are seeking to change that — athenaInsight recently sat down with three physicians who share how some fairly simple interventions could change the course of CKD in the U.S.
Why is chronic kidney disease an ideal candidate for value-based care?
Chris Moriates, M.D., Assistant Dean for Healthcare Value, Dell Medical School: One, it's chronic and progressing. So it's ideal to have longitudinal, team-based care across the continuum. Two, it's pretty easy to identify and deploy the resources for those who need it. Since you can base the diagnosis on a lab result, you can readily identify those patients.
Carmen A. Peralta, M.D., Chief Medical Officer Cricket Health and Professor of Medicine and Co-Founder of the Kidney Health Research Collaborative at UCSF: It’s highly prevalent, and typically not symptomatic. However, we know how to find it. We know what the tests are to identify it. We know what populations are affected. We know the risk factors for complications. We also know that we have therapies that can slow the progression — or at least prevent complications.
Moriates: And since there's both widespread underuse and overuse in patients with CKD, there are a lot of opportunities to change the course of testing and interventions for these patients. To make simple recommendations about what people should and should not get based on their needs, which could make a significant impact on both outcomes and costs.
Peralta: One of the other elements going for value-based care is data availability— being able to leverage electronic health records and claims data. In regular blood tests typically done by a doctor, there's a measure of kidney function, which is called creatinine. So, you could mine EHRs and claims databases to find people who have kidney disease but haven’t been diagnosed, and re-stratify them appropriately for care.
What does a value-based approach to CKD look like?
Peralta: Number one: We need to proactively look for affected persons. To do that, we can leverage the EHR looking at known medical and demographic risk factors for CKD. This lightens the load on primary care physicians. Two: When kidney disease is discovered, for the vast majority, it’s really about empowering and supporting the primary care doctor to care for that patient because the early interventions are typically focused on treating the risk factors and adding some specific medications. We have shown that this can also be done in the EHR with embedded decision supports.
Tessa Novick, M.D., Nephrologist, Department of Internal Medicine, Dell Medical School: Yes, early on, kidney disease can be managed by the primary care physician. And with some simple interventions, you can potentially prevent progression in a lot of people. And if we can improve our interventions before they reach end-stage, we can prevent a lot of people from even reaching end-stage and have a much broader impact.
Moriates: All of us primary docs want to do right by our patients. Sometimes you just don’t have specific expertise around a disease state, about what needs to be done for your specific patient. So to me, having somebody who can help give you those recommendations upstream is a perfect model of where primary care and specialty care can team-up without just simply sending everybody to a nephrologist.
Novick: In Texas, many uninsured or undocumented patients are receiving emergency-only dialysis, which is associated with substantially higher mortality, morbidity, and just quality of life. They can’t get standard of care because they are uninsured. What we’re trying to do here at Dell Med is improve care for this population along the entire spectrum. Trying to get them into the clinic when they have CKD, before they reach ESKD, improving diagnosis and preventing progression.
Peralta: Even when CKD is very advanced, and the patient needs to see a nephrologist, it should be about co-management with multidisciplinary clinicians and patient education. The patient should have the chance to receive education about types of dialysis, conservative care without dialysis, and transplantation. By putting the system to work in this way, you return something that has been robbed from the patient — the ability to make informed choices.
What wraparound care is required to make this work?
Moriates: I think the multidisciplinary team-based aspect is key. There are published models about how multidisciplinary care — say a renal disease clinic that doesn't just have a nephrologist but rather also has a nutritionist and a clinical social worker, and the ability to work closely with a vascular surgeon when needed — has improved outcomes in these patients. It's focused around the patient’s need, not around the specialty or the expertise of that specific clinician.
Peralta: That is the right question, and I don’t think that’s unique for kidney diseases. I think the way we think about value-based care — if we’re really going to pay for having better outcomes — is that we have to integrate it, and we have to empower the clinicians with support. We need wraparound care of the patient because social determinants of health make up an enormous part of determining which way a patient’s journey might go. You can't have value-based discussions and not be willing to pay for some of these things, like pay for transportation or have the healthcare system come to them. And there needs to be a lot of work in the area of health literacy. For clinicians, we need to build an ecosystem that allows the nephrologist and the PCP to work together, which reduces their burden and enables them to focus on the medical care.
Novick: We are planning to do a lot of patient education with immigrant or uninsured patient populations. They are coming in with kidney failure, and they’re not getting any education. There's a language barrier. There are trust issues. And I think there's really poor awareness of what's going on and their patient rights. And in general, that whole education process needs to be improved.
Peralta: Somebody might be able to speak and write English. But being able to understand all the information given to them, and make health decisions? That’s huge. I mean, people are making life or death, life-changing decisions when they're thinking about their journey for kidney disease.
Novick: Dell Med is working with the communications school to create a set of videos that people can watch at home with their families or in the hospital to explain kidney disease in a culturally competent manner. They deserve and need to understand what's going on, and learn how to prevent symptoms, and to take care of themselves, and what programs they might be eligible for. The other thing I’d love to do is create specific clinics for this population, where it can be interdisciplinary. We can have appointments with a nutritionist and a community health worker from their community.
What is the potential impact?
Peralta: My sense is that, at this point, dialysis is good business for the large entities that are providing in-center dialysis. But it’s not good business for the patient. It’s not good business for the payer. And certainly not good business for Medicare or any commercial payer.
Novick: The cost of dialysis is astronomical. Standard outpatient hemodialysis is over $88,000 per person annually, and the cost is four to eight times that for emergency only hemodialysis. And, people with kidney disease are actually more likely to die of heart disease, but we know that they do so much better when they have nephrology care. If we really focus on diagnosing, preventing progression, and cardiovascular risk reduction, I think we could really improve outcomes.
Peralta: Randomized trials suggest that, by focusing earlier, you can reduce hospitalizations. You can reduce utilizations in general. You can reduce adverse outcomes. And then, in some sub-groups, you can actually slow down the disease. Even if, despite your best efforts, you don’t slow it down, patient education allows them to be listed for a kidney transplant or find a living donor. That alone will save millions of dollars.
Novick: And dialysis is associated with a tremendous patient burden. They have huge medication regimens. They have to go to a million appointments, in addition to their dialysis sessions several times a week. It prevents people from working, and they have very strict dietary restrictions.
Peralta: By realigning the incentives to early care, it’s not only better for the patient, it’s also better for the payers, better for the clinicians, and better for the system. So to me, there are value propositions for every stakeholder. And also, frankly, I think it allows the doctor to do what they know that they need to do.
Lia Novotny is contributing editor of athenaInsight