Issue: April 2022
Disclosures: Gupta, Riopelle and Wong report no relevant financial disclosures.
April 19, 2022
6 min read

Medicare’s aggressive approach to CKD attracts providers, value-based care groups

Issue: April 2022
Disclosures: Gupta, Riopelle and Wong report no relevant financial disclosures.
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Dialysis providers saw a change in the payment model for treating Medicare patients when CMS instituted the Prospective Payment System in 2011.

Bundling the payments to providers streamlined expenditures for a costly federally funded entitlement that absorbed 7% of the Medicare budget.

But that approach stopped at the door of the most complex aspect of care: managing chronic kidney disease.

In a 2021 report, the CDC estimated more than one in seven, or 15% of adults in the United States, have CKD in stages ranging from 1 through 5.

Many have diabetes, obesity, uncontrolled hypertension and, in some cases, limited access to care.

Changes ahead

Value-based companies are focusing on better treatment options for the 37 million patients with CKD, as both Medicare and commercial payers grapple with the high cost of hospitalizations and try to correct the haphazard treatment approaches of the past for kidney disease.

“Of the patients we have engaged with in our program, more than 50% with CKD stages 4 to 5 have never seen a nephrologist,” Chris Riopelle, CEO and co-founder of Strive Health, told Nephrology News & Issues.

Leslie Wong, MD, chief medical officer for Nephrology Care Alliance, a physician-led value-based care entity by DaVita, agreed that the interest in CKD is changing.

“We have started moving that focus upstream,” Wong told Nephrology News & Issues. “So many nephrologists across the country have spent most of their time, most of their careers, dealing with dialysis-related issues. We rarely get called to a hospital to talk to someone about preventing their kidney disease from getting worse.

Leslie Wong

“It is like the Titanic hitting the iceberg, and all we can do is start bailing.”

Several changes have occurred in the last 3 years that have placed CKD in the spotlight, including the following:

  • New pharmaceuticals that not only treat the underlying conditions of patients with CKD, such as cardiovascular disease and diabetes, but also help slow the progression of kidney disease.
  • Advancing American Kidney Health, introduced in 2019, was a government-funded initiative aimed at addressing kidney disease, including setting goals to have clinicians steer more patients to transplantation and home dialysis, which have better long-term outcomes.
  • From the initiative came the ESRD Treatment Choices Model demonstration, which rewards clinics for directing more patients to self-care at home and to kidney transplantation, and the Kidney Care Choices (KCC) demonstration, launched this past January with a focus on slowing the progression of CKD at stages 4 to 5.

The KCC demonstration runs through December 2026 and includes two models: one for dialysis providers and nephrologists, called Kidney Care First, and a second for nephrology practices and transplant organizations, called Comprehensive Kidney Care Contracting. Both are for Medicare primary patients only and are subject to clinical quality measures established in the Quality Incentive Program, patient activation measures as well as measures tracking hospital readmissions for depression and optimal starts for patients with ESKD.

Early intervention

Strive Health along with other value-based companies, like CVS Kidney Care, Evergreen Nephrology, Somatus Inc., Panoramic Health, Cricket Health and Monogram Health, are joining kidney care organizations like DaVita Inc., Fresenius Medical Care and U.S. Renal Care, in participating in the KCC demonstration.

DaVita’s Integrated Kidney Care division will manage 11 Kidney Care Entities (KCEs) under the Comprehensive Kidney Care Contracting model; Fresenius Medical Care North America’s Integrated Care Group will manage 20 KCEs.

“There’s an opportunity to make a positive difference in the lives of more patients by reaching them with the right interventions and education before their kidneys fail,” Misha Palecek, chief transformation officer for DaVita, said in a press release. “We can help patients better plan for their future kidney care needs – whether that is a preemptive transplant or an optimal start on dialysis at home – and improve their overall health while helping reduce the cost to our health care system.”

“Our innovative solutions have shown we can truly make a difference as we work to intervene earlier to treat kidney disease under new value-based models of care,” David Pollack, president of FMCNA’s Integrated Care Group, said in a release.

Cricket Health, FMCNA combine

Most of the physicians FMCNA partners with are investors in its Health Partners subsidiary called InterWell Health, which has a network FMCNA recently announced it planned to merge InterWell Health and Fresenius Health Partners with Cricket Health, a value-based company focused on kidney disease. Once the merger is finalized, the new company will be called InterWell Health and be headed by Robert Sepucha (bf), who was a key player 3 years ago in the founding of Cricket Health.

“Each patient’s situation and needs are unique, and the new organization will offer groundbreaking solutions from machine learning to highly personalized engagement that keep patients healthy, at home and out of the hospital,” Sepucha said in a press release.

New partnerships

The University of Pennsylvania Health System (UPHS) recently announced it was partnering with Evergreen Nephrology to provide care for Medicare patients with kidney disease.

UPHS said 43 Penn Medicine nephrologists intend to join the partnership and, in the upcoming months, up to 600 patients will be given the opportunity to sign up for the program.

“We founded Evergreen Nephrology because we know the existing models of care didn’t tackle the root of the problems for many patients with kidney disease — the need for full, comprehensive care to help them better manage the disease,” Adam Boehler, executive chairperson and co-founder of Evergreen Nephrology, said in a release.

Boehler was part of the CMMI team that managed the Comprehensive ESRD Care model from 2015 to 2021 that included teams of dialysis providers, nephrologists and other specialists to provide comprehensive care to patients with ESKD.

Somatus announced in February that it has raised more than $325 million to develop its value-based kidney care model.

“This investment puts us in a great position to fund the expansion of our proven care model and continue building a nationwide network of providers and connected patients, who alongside our care teams are working together to improve lives and transform the industry,” Ikenna Okezie, MD, CEO and co-founder of Somatus said in a press release.

CVS Kidney Care is developing an integrated Renal Care Network in which services are provided to help practices develop home dialysis-based programs (the company is also developing a new home hemodialysis machine, now in clinical trials).

Strive CEO Riopelle sees self-care at home as the best modality to provide superior outcomes and help contain costs.

“Home has to be everybody’s mantra – it is a big part of what we are doing,” Riopelle said.

Shaminder Gupta

Care at home is the preferred option advocated by Monogram Health for patients with CKD who need to move toward treatment, Shaminder Gupta, MD, FACP, chief medical officer, told Nephrology News & Issues.

Gupta said the company works with payers to conduct at-home visits when patients are in stage 3b, or at an eGFR of 45 mL/min/1.73 m² and below.

“Our in home model utilizes nurse practitioners doing in home visits supported by internists, nephrologists, endocrinologists, cardiologists and palliative care physicians,” Gupta said.” Gupta said.

Conservative care is also an option at that stage and “we present that as part of our assessment to nephrologists,” Gupta said. About 30% of Monogram’s patients choose conservative care.

Monogram now has contracts with payers in 34 states.

Riopelle said his company has partnerships with more than 500 nephrologists who provide CKD preventive services, and the outcomes have been good.

“We have seen 30-day admissions down by 36% and almost a 50% reduction in hospitalizations among high-risk patients,” Riopelle said. “We have also seen a 67% increase in optimal starts,” Riopelle said.

“Nephrologists are getting data on patients now that they never were able to get before, and they would rather spend their time helping to slow progression of kidney disease,” Riopelle said.

“Doctors want to do this.”

Gupta agreed, citing the goals of all the value-based organizations. “We all move forward if we all do well,” he said. – by Mark E. Neumann