September 03, 2019
3 min read

Changes in practice are needed to make CKD-ESKD model successful

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The government took a bold step in payment reform in July with the announcement of five new Centers for Medicare and Medicaid Innovation-designed payment models for physicians and dialysis providers. Ultimately, this movement away from fee-for-service payment toward value-based reimbursement is a fundamental step in the process of aligning health care providers around the holistic care for patients, especially upstream in chronic kidney disease.

Jeffrey Giullian

For a physician practice to participate in one of the voluntary models, with an emphasis on slowing the decline of renal function, it will require a significant change in how care is delivered. Archetypes like the Chronic Care Model (CCM), described by Wagner and colleagues in 1998, are based on comprehensive system change, including clinical optimization, advanced care coordination, integration with community-based resources and patient self-care.1 More than 2 decades later, this holistic approach is likely our best option to meaningfully impact the rate of renal decline in patients with CKD. For most practices, this quartet can only be delivered with technology-based solutions, community partnerships and a team-based approach that includes the patient and their caregiver.

To begin, clinical optimization and adherence to practice guidelines may best be achieved through technology-based population health management tools, including integrated decision support. Whether embedded within the electronic health record or separate, these tools are fundamental for reviewing patient-specific data and population-wide trends. However, this technology alone is useless if not implemented in a manner that both helps the practice act on the data and holds itself accountable for the results. Practices whose governance structure is not set up for such accountability would best be served by first developing a culture of accountability among providers.

Next, practice transformation of this magnitude depends upon a shift away from the traditional patient-physician relationship to a team-based approach. Such physician-led, multidisciplinary teams can help meet the complex needs of patients with chronic illness,2 including enhancing clinical interactions, providing advanced care coordination and encouraging greater patient engagement. This type of patient-centered, team-based care has been defined as “relationship-based with an orientation toward the whole person, that includes partnering with patients and their families to understand and respect each patient’s unique needs ... also supports patients in learning to manage, organize and participate in their own care at the level the patient chooses.”3

In the nephrology setting, this team could include non-physician practitioners, a navigator,4 a dietitian, a social worker and a medical assistant. Platforms for HIPAA-compliant telehealth and team communication further augment this approach. In an expanded format, the team could also incorporate community-based resources, such as kidney disease education, behavior health specialists and social services.


Funding such radical practice transformation may require a combination of both fee-for-service (FFS) and payment model reimbursement. Three of the voluntary models qualify as Advanced Alternative Payment Models (AAPM) and may make physicians eligible for a 5% bonus on all Medicare FFS payments. Additionally, practices may consider documenting and billing CPT codes for appropriate Chronic Care Management (CCM), Transitional Care Management (TCM), Kidney Disease Education (KDE) and Advance Care Planning. Notably, the Centers for Medicare and Medicaid Innovation is planning significant enhancements to the KDE benefit by expanding this offering to patients with CKD stage 5 and to the TCM benefit, expanding it to patients with ESRD.

Optimistically, payment reform will position practices to begin changing the delivery of advanced renal care. Ideally, this approach will facilitate individualized care, patient/family member education and shared decision making — each of which are likely to improve clinical outcomes while reducing cost.

However, the benefits are not just for patients and society. Physicians have a lot to gain from such transformation. This new model, whereby the physician serves as the “captain” but not the sole provider, may offer new solutions for addressing the nephrologist capacity crisis and physician burnout.5

Ultimately, these novel payment strategies comprise an experiment by CMS. If successful at improving care, reducing costs or both, we are likely to see more value-based reimbursement options. Assuming appropriate oversight to ensure the validity of this experiment, to which CMS appears committed, the comparison of outcomes for patients inside and outside of these models will shape payment policy well into the future. Those who participate by choice or by mandate will ultimately chart the path for the rest of the country and the rest of health care.


Disclosure: Giullian reports no relevant financial disclosures.

To read further Viewpoints on this subject, click here and here.