A Proposed Model for Comprehensive Chronic Kidney Disease Care from the National Kidney Foundation

Accessible healthcare that puts patients first is the most important goal that any new model for payment and care delivery should have at its center. The shift from a fee-for-service system toward reimbursement for delivering value has great potential to improve patient outcomes through better engagement. This shift in payment also creates opportunities for a more rewarding career environment for healthcare practitioners by providing the resources necessary to support earlier intervention and strengthen patient engagement. Early on, the National Kidney Foundation recognized the potential of value-based payment models as an opportunity to address a question that we hear from our patients who are living with ESRD.

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Why did I not know I had kidney disease?

In June 2016, the National Kidney Foundation established a multidisciplinary workgroup that included patients, family physicians, internal medicine physicians, nephrologists, advanced practitioners, a dietitian, and a social worker to develop a payment model to improve earlier detection and treatment of chronic kidney disease (CKD), promote collaborative evidence-based care delivery to patients at each point in their CKD journey, and encourage collaboration between primary care and nephrology practitioners to ease transitions for patients who experience progression toward ESRD.

Often in healthcare, particularly kidney care, we wait until a patient’s condition is medically complex and costly to the healthcare system before intervening. Current models in kidney care have focused primarily on the care of dialysis patients to reduce the costs generated by this highly expensive population. The CKDintercept: Comprehensive Chronic Kidney Disease Care Model seeks to change this by providing primary care practitioners and nephrologists care management payments tied to quality measures to deliver targeted, individualized care to patients with CKD across the longitudinal spectrum of this condition.

In this model, not every patient with CKD would be viewed as being in a “predialysis” state, as is so common now. Instead, care would focus on delaying progression, avoiding complications, and engaging patients in shared decision-making and self-management. For patients who may ultimately experience progression to ESRD despite best efforts, this model promotes easier transitions and informed decision-making about treatment options in advance of kidney failure—including how treatment options such as transplantation, home dialysis, in-center dialysis, or supportive end-of-life care can help patients achieve their goals and be responsive to their values and preferences.

The CKDintercept model presents the opportunity for primary care and nephrology providers to form organizations and receive tiered monthly payments for tailored kidney care management. The model also allows patients to receive care in their current healthcare setting and promotes collaboration with nephrology practitioners in an evidence-based and cost-effective manner.

CKDintercept organizations (CKDi-O) would receive per-beneficiary per-month payments (PBPM) for the management of CKD stages 3 through the transition to ESRD. This fee is intended to help support implementation of a multi-disciplinary care team to help with care coordination, remote monitoring, nutrition, and medication management. A Performance-based Incentive Payment (PBIP) would also be available, contingent on performance for CKD-related quality measures and lowering CKD-related expenditures.

CKDI-Os would take on risk beginning in year two of the model, allowing those providers to achieve advanced alternative payment model (AAPM) participation status. Attribution in the model would be prospective assignment of beneficiaries based on plurality of primary care or nephrology claims to providers in the CKDI-O. Beneficiaries would also be allowed to voluntarily opt in by self-selecting a participating provider. Participation would be contingent on an appropriate percentage of the practitioner’s attributed diabetic and hypertension population with an estimated GFR and urine ACR in alignment with the Kidney Disease: Improving Global Outcomes/Kidney Disease Outcomes Quality Initiative guidelines that successfully achieve selected measures specific to delivering CKD care.

CKDI-O providers would also need to participate in practice transformation activities, which is common for other AAPMs. Recommended activities include integrated mental health, nutrition counseling, advanced care planning, development of patient and family advisory councils, and use of shared decision-making tools.

The CKDintercept model is intended to allow primary care physicians (PCPs) and nephrologists to participate regardless of practice size or experience with APMs. For PCPs and nephrologists who are participating in other APMs, the model can be tailored to allow for cross-participation. The National Kidney Foundation encourages the participation of community health centers and their practitioners because CKD has a disproportionate impact on individuals with social risk factors.

Value over volume

The CKDintercept model enhances care delivery by establishing a set of criteria to allow participants flexibility in designing the plan specifically to address each criterion during the application process (Table 1). The model defines which services would not be separately billable in fee for service. The criteria outline what is necessary to improve quality, lower costs, and enhance patient engagement while allowing participating practitioners flexibility in how they would address the criteria. Because the model proposes payment to practitioners up front monthly as opposed to a shared savings arrangement, the initial investments by practices to meet the criteria should be recovered in a relatively short time. This approach is similar to what is used in the Oncology Care Model.

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We can, and we must, do better for patients now. We must develop and test new models of care that promote earlier detection of those at highest risk for the disease and improved treatment of those with it. As a kidney community we must stop looking at individuals with CKD as being in a “predialysis” state and focus on delivering the right care to the right patient at the right point in time. Delivering on this promise of earlier and better care will take the engagement of the primary care community and kidney community and a commitment to work together. The CKDintercept model is a work in progress. The organizations that represent these communities must come to the table to help shape the details for this model, support its testing, and solve the perceived challenges that a new model of care poses. Only through this coordinated effort can we truly improve the lives of kidney patients.

Full details of the National Kidney Foundation’s proposed model, including the proposed quality measures and evidence base, can be found at https://www.kidney.org/sites/default/files/20171120-CKDintercept-Comprehensive-CKD-Care-Model_CMMI-RFI.pdf.

October/November 2018 (Vol. 10, Number 10 & 11)