Issue: March 2021
Disclosures: Ketchersid and Wong report no relevant financial disclosures. Patel reports she is a member of the board of directors for Strive Health.
March 18, 2021
7 min read
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Kidney Care Choices models address urgent need to improve detection, management of CKD

Issue: March 2021
Disclosures: Ketchersid and Wong report no relevant financial disclosures. Patel reports she is a member of the board of directors for Strive Health.
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According to the National Kidney Foundation, 1:7 people in the United States – about 15% of the adult population – have some form of chronic kidney disease.

Those numbers – accounting for close to 37 million residents – worry Kavita Patel, MD, a primary care physician who works 2 to 3 days a week at Mary’s Center, a federally qualified health clinic in Washington, D.C., where she sees patients who have been left out of mainstream health care in the United States.

“I will have appointments with 32 patients today; 18 have diabetes. Many of them are getting ready to go on dialysis,” Patel told Nephrology News & Issues. “I have not seen a commercial payer patient or Medicare patient in several years.

“We need to figure out how to make a CKD treatment program worthwhile for this population.”

Patel recently joined the board of directors of Strive Health, which partners with health care payers and providers to develop integrated care delivery systems for patients with CKD and end-stage kidney disease.

Leslie Wong, MD, chief medical officer of Nephrology Care Alliance, said nephrologists should be directly involved in the care of patients before kidney failure.

Source: DaVita Inc.

New approach

As a non-resident fellow in the department of economic studies at the Brookings Institution, Patel helps health care systems change their clinical environments to become more accountable for the care they offer to patients who check in at places like Mary’s Center.

“You won’t meet a lot of people on boards of companies who also work in a public community health center,” Patel said. “This is relevant to my life. Kidney disease impacts a substantial percentage of U.S. adults, and the percentage continues to grow.”

CMS wants to target these patients with its Kidney Care Choices (KCC) demonstration, scheduled to start in April. The agency has been reviewing applications for the voluntary models, which have four variants (see sidebar).

CKD-ESRD model

Kavita Patel

Unlike the End-Stage Renal Disease Treatment Choices Model, which provides financial incentives for home dialysis and pushes dialysis providers to direct more patients for transplant evaluations, the KCC models “piggyback” CKD care onto CMS’ existing Comprehensive ESRD Care (CEC) Model structure. That involves dialysis facilities, nephrologists and other health care providers partnering with ACOs to manage care for beneficiaries with ESKD, as well as receive financial incentives to manage the care for Medicare beneficiaries with CKD stages 4 and 5.

Initial results from the CEC model “demonstrate early findings from the CEC model demonstrate that a specialty accountable care organization model focused on a particular population was associated with reduced payments and improved quality of care,” Grecia Marrufo, PhD, of the policy research organization The Lewin Group, and others wrote in JAMA Internal Medicine.

Early intervention

Dialysis organizations DaVita Inc. and Fresenius Medical Care North America, which manage almost 70% of the U.S. dialysis population, have formed physician-based organizations that will direct some of the KCC models. Leslie Wong, MD, and Terry Ketchersid, MD, lead physician-directed organizations at DaVita and FMCNA, respectively, and see Kidney Care First as an opportunity to even the kidney disease playing field.

“We see far too many patients at the later stages of CKD, where we don’t have much lead time before they experience kidney failure, including those whose first encounter with us is in the hospital when they have to start dialysis emergently,” Wong told Nephrology News & Issues. “Conversely, when patients are referred in time, we have time to develop a relationship with patients so we can work together as a team to slow CKD progression, optimize cardiovascular health, and start the individualized process of life planning so patients can choose what treatment options make the most sense for their life goals.”

Wong leads Nephrology Care Alliance (NCA). The three main goals of the organization include the following:

help nephrologists stay informed about different value-based program opportunities. “We provide education and information about the different value-based care programs from the government, such as Kidney Care First, and from commercial insurance companies,” Wong said;

share best-in-class tools and services to help practices succeed in value-based care. “As we migrate from practicing medicine the old-fashioned way to the new realm of nephrology with analytics and population health, it is imperative we get access to resources that are customized to the needs of nephrologists to help us provide the best possible care for patients with CKD. This is the centerpiece of the tools and capabilities we have built at NCA,” Wong said; and

create collaborative communities of nephrologists. “We are more effective working together as a like-minded community making strides toward the future,” Wong said. “It’s not only about best practices; collaboration is key in value-based care.”

Ketchersid said the KCC models, while not perfect, offer the kidney community some new opportunities to take charge of the large CKD population. Near the end of 2019, FMCNA helped establish InterWell Health, a physician-centric population health company. Today the InterWell Network includes 1,300 nephrologists who care for patients in 37 states.

“The InterWell network participates in a number of value-based care arrangements with both public and private payers, and these value-based care arrangements include patients with both ESKD and CKD,” Ketchersid told Nephrology News & Issues. “But nephrologists alone have a difficult time meeting the needs of value-based care. To that end, Fresenius Health Partners (FHP) has developed and deployed Kidney Care: 365, a national care coordination program designed specifically to support nephrologists in the delivery of care and better educate patients about how to help slow the progression of their advanced kidney disease.”

Wong said payers who previously paid little attention to kidney disease are now cognizant of the bigger costs associated with CKD. They want nephrologists to not only be in charge but also accept the risks – and rewards – of determining the right treatment plan.

“Rising health care costs have payers looking to physicians to take more accountability and financial risk for CKD and ESKD care in order to reduce avoidable health care costs,” Wong said. “In order to encourage successful engagement in value-based care (VBC) environments, NCA has established a clinical incentive program to reward physicians for superior clinical outcomes. Our performance program enables physicians an upside-only entry point for participation to help start the journey toward VBC.

“I think nephrologists know what goals they should be focusing on when it comes to managing CKD,” Wong said. “That is – keeping patients healthy and off dialysis. We just have not had the right payment models and support to help us deliver on that goal.”

Both Wong and Ketchersid said nephrologists will steer CKD interventions to help reduce the risk of kidney failure.

“Nephrologists will lead the way,” Wong said. “Nephrologists will be the reason why the conversation shifts from managing kidney disease to improving health for the patients we serve.”

“The undisputed captain of this ship is the nephrologist,” Ketchersid said. “Absent leadership from the nephrologist, these programs will fail.

“But nephrologists alone have a tough hill to climb. Most practices today are optimized to function in a fee-for-service environment where no one is paid unless there is a face-to-face encounter with a patient,” Ketchersid said. “Value-based care programs change that paradigm such that work done to influence patient choice and behavior between visits with the provider impacts the total cost of care, creating a funding mechanism to support services no one can afford within a fee-for-service framework.”

The KCC models award nephrologists who deliver value-based care.

Terry Ketchersid

“When you support nephrologists with care coordination solutions, you create a model that reduces costs while improving quality,” Ketchersid said. “Optimal ESRD starts is a great example. As a key measure in the new Kidney Care Choices models, when a CKD patient has a planned start to dialysis, the total cost of care decreases, model participants are rewarded financially, and most importantly, the patient has a superior outcome.”

Program changes

Ketchersid said changes to the KCC models made by CMS since January 2020 are beneficial to nephrologists and should encourage more interest.

“The nephrologist’s (monthly capitated payment) MCP will not be discounted to the two to three visit in-center MCP as originally described, and they will be paid directly to the nephrologist just as they are today,” Ketchersid said.

A home dialysis payment add-on “is effectively a bonus paid for every home MCP delivered to an aligned patient during the performance year and it appears to be an attempt to create parity between the four-plus visit in-center MCP and the home MCP,” he said.

Within the KCF option, quality measures have been clarified and simplified. Wong and Ketchersid said the KCC demonstration will lead the nephrology community in the right direction – value-based care with a gradual decline in fee-for-service payments. However, the model could go further.

“While the KCC models include stage 4 and 5 CKD patients, one might argue the best opportunity to prevent or delay the development of ESKD occurs earlier than this,” Ketchersid said. “I am also skeptical the incentives within the Kidney Care First model are large enough to impact care delivery. The CKCC model, on the other hand, may make a difference. As a total cost of care model, the stakes are substantially higher.

“As we have seen in the past, when providers voluntarily take financial risk, good things often happen,” he said.

Editor’s Note: On March 5, 2021, CMS announced it would delay the Kidney Care Choices demonstration until January 2022.