Issue: January 2022
Disclosures: Ketchersid, Lin and Miller report no relevant financial disclosures.
January 19, 2022
6 min read
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CKD moves to center stage with launch of Kidney Care Choices model

Issue: January 2022
Disclosures: Ketchersid, Lin and Miller report no relevant financial disclosures.
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Brent W. Miller, MD, has always believed that caring for patients with chronic kidney disease should be the true calling for nephrology.

“Moving upstream in the diagnosis and treatment of CKD is absolutely the correct decision. In fact, I would argue for [starting] at stage CKD 3,” Miller, the Michael A. Kraus Professor of Clinical Medicine at Indiana University School of Medicine, said. “Nephrology has spent so much effort and money on the treatment of the final stages of kidney failure and ‘moonshot’ attempts at building an artificial kidney. While those are both important enterprises, a patient would rather prevent the need for these therapies.”

That decision was made by the Centers for Medicare and Medicaid Innovation (CMMI) in its launch of the Kidney Care Choices model. The 5-year voluntary demonstration will focus on paying nephrologists and their practice team to care for patients who are in CKD stages 4 and 5.

Payment options

The Kidney Care Choices model will have four payment options for practices that participate: CMS Kidney Care First (KCF) Option, Comprehensive Kidney Care Contracting (CKCC) Graduated Option, CKCC Professional Option, and CKCC Global Option, according to the CMMI website.

Eugene Lin

Eugene Lin, MD, MS, FASN, an assistant professor of medicine in the division of nephrology and hypertension at the Keck Medical Center in Los Angeles, agrees that CKD needs a special focus.

“Intervening upstream of dialysis is the biggest opportunity for policymakers to improve outcomes in kidney disease,” Lin told Nephrology News & Issues. “A comprehensive policy that targets all aspects of CKD would of course be ideal. However, I worry that such a large bite will result in an overly complex policy that isn’t implemented well. There is so much low-hanging fruit at stages 4 and 5.”

Advancing kidney health

In July 2019, President Donald J. Trump signed an executive order aimed at improving outcomes for individuals with kidney disease. The resulting Advancing American Kidney Health initiative spawned a number of key goals, including a plan to care for patients with kidney disease much sooner to help slow down the disease.

Under Medicare’s End-Stage Renal Disease Program, Medicare covers the cost of dialysis and transplant care, but has never assembled a coordinated program to treat patients before the kidneys fail.

“The care of patients with advanced kidney disease in the United States remains siloed, with multiple incentives resulting in greater focus on care delivery to the patient population who are highly vulnerable and on dialysis than to other CKD populations,” Gaurav Jain, MD, from the department of medicine, University of Alabama in Birmingham, Alabama, and Daniel Weiner, MD, from the department of nephrology at Tufts Medical Center, wrote in a study published in Kidney360. “In contrast to the highly structured processes in place for dialysis care, there are few organized, well-funded programs that target preventing or slowing progression of kidney disease among individuals with CKD, promote a smooth transition to kidney replacement therapy if necessary and desired by the patient, and encourage kidney transplantation and home dialysis.”

The Kidney Care Choices models must include nephrology practices and transplant providers and, although not mandated, will also require extensive involvement of a dialysis organization as a partner to be successful, according to the CMS website.

“Both models incorporate capitated payments, increasing the [monthly capitation payment] MCP to clinicians for home dialysis to match the four or more visits per month threshold for patients who are in-center and adding a new quarterly capitated payment (QCP) for beneficiaries with CKD stage 4–5 that is equivalent to the prior 2–3 visit monthly MCP for patients on in-center hemodialysis,” the agency said.

That level of cooperation needs to also include the primary care physician, Lin said.

“In my opinion, PCPs should always have a role because patients with CKD have so many other issues that require complex care-coordination. Ideally, we’d have an organic process that allows the nephrologist to gradually take on more responsibilities,” Lin said.

“One challenge is that our current system forces patients to cater to physicians’ schedules – that means patients must repeatedly travel to many different physician appointments, increasing the likelihood that something gets missed. My dream would be to see a restructuring of multidisciplinary care, so patients can have all their needs addressed in a ‘one-stop shop,’” he said.

New developments in CKD

Nephrologists who spoke with Nephrology News & Issues said a demonstration testing the community’s ability to intervene earlier with kidney disease is important and overdue.

“One of the goals of this model is to delay the need for dialysis and encourage kidney transplantation. Doing so reduces expensive hospitalizations paid by Medicare while improving patient outcomes,” Terry Ketchersid, MD, MBA, chief medical officer of the Integrated Care Group at Fresenius Medical Care North America, and co-chief medical officer of InterWell Health, told Nephrology News & Issues.

“With the nephrologist as the principal care provider, the new care team will include a dedicated care coordinator resource,” Ketchersid said. “Under the direction of the nephrologist, the care coordinators will ensure the patient’s plan of care is carried out. The care team will also include access to many things we have taken for granted in the ESKD population, such as ensuring that patients with advanced renal disease have access to social workers and renal dietitians.

“The opportunities for advanced practice providers, like nurse practitioners and physician assistants, will almost certainly expand in this new model,” Ketchersid said.

Miller, an advocate for home dialysis, said new tools to treat CKD are starting to appear in both diagnostics and treatments, however, the applications of the tools need to reach scale, a challenging task.

“I have spoken with 14 companies over the last 2 years that are entering the CKD management business. Several have now contracted with major insurers and health systems,” Miller, a member of the Nephrology News & Issues Editorial Advisory Board, said. “My employer, Indiana University Health, which is the largest health care system in Indiana, has approximately 45,000 patients with CKD stage 3 and above. I think about those 45,000 people daily – some are members of my family. Algorithms that identify risk progression and tools that address the genetics, epigenetics, proteomics and metabolomics of CKD will soon appear. Therapies that are specific to each patient will follow.”

Economic scale

Miller has some reservations about where the KCC model will work.

“The major problems are the scale of the economic upside and downside of the program, the delays in implementation and the complexity and continually changing of the rules,” Miller said. “Because of this, very few people are engaged in the program ... it won’t change practice for the overwhelming majority of nephrologists or patients.

Brent W. Miller

“I have no problems with the goals of less ESKD, more pre-emptive transplant and more home dialysis. But a staged approach to achieving this would have been better. As the old adage goes, “if it were easy, it would have already been done.”

Miller said the payment approach to the demonstration – paying nephrologists separately for CKD care – makes sense.

“A separate payment structure for CKD 3-5 is a step in the right direction. However, the rules of the payment system are incredibly complex and not accessible to a smaller nephrology practice. But the direction of the program – to finally address pre-dialysis care in efforts to avoid it – have a lot of potential,” he said.

“It is heartening and among CMS’ best efforts in my professional career. That is important to recognize. The shortcomings of the implementation do not take away from the ultimate goals and hopefully will not end those efforts,” Miller said.

Ketchersid said CMMI was created by Congress to test new payment models. The organization is now entering its second decade.

“At the end of the day, I believe CMMI is trying to answer a simple question – Are patients with advanced renal disease different enough that they require a unique payment model? If they determine the answer is yes, I think we will see a fundamental change to the way nephrologists are paid to care for this patient population. Success will require stepping off of the [relative value units] RVU treadmill and creating and leading care teams that are focused on patient outcomes. This will take time and of course it needs to happen while a sizeable amount of practice revenue continues to emerge from fee for service. But practices participating in these new payment models are developing the muscle memory necessary to succeed.”