Integration across medical settings and disease phases, led by nephrologists serving as principal care providers, will improve care quality and patient outcomes in advanced kidney disease through renal replacement therapy, end-of-life care, or both.
This statement is the thesis for the kidney care delivery model that the American Society of Nephrology (ASN) is currently developing to submit to the Physician-Focused Technical Payment Advisory Committee (P-TAC), emphasizing that nephrology professionals can improve care, improve patient-centeredness of care, and add value to the healthcare system by spanning care settings and disease phases. In doing so, nephrologists can reinforce a healthcare system in which patients are at the center and their providers are with them.
Before diving into the details of the ASN concept, let’s review the current care delivery and payment model policy. In 2015, Congress enacted the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA), a bill that overhauled the physician payment system and put us on a path to rewarding value (how well patients do versus cost of care) instead of volume (how many patients receive care). MACRA created incentives, which will increase over time, for physicians to provide care through alternative payment models—models that take on financial risk and provide more coordinated patient care. MACRA also created the P-TAC, an independent body of expert clinicians and health economists, to evaluate new suggestions for physician-led alternative payment models.
The kidney community was fortunate that the ESRD Seamless Care Organization (ESCO) program met the standards for qualifying as an alternative payment model, affording some nephrology health professionals the opportunity to test new ways of delivering kidney care (and, thanks to MACRA, receive a payment bonus along the way). The ESCO program has shown significant early success; ESCOs achieved $75 million in savings and improved outcomes in the first year, signaling the potential for more coordinated care to benefit patients with kidney diseases.
However, one significant limitation of the ESCO program is that it starts and ends with dialysis care. Although important gains can be made in improving dialysis care and patient outcomes, the greatest gains for patients would likely occur earlier in the course of kidney disease by slowing the progression to the extent possible and by preparing patients for a smooth transition to a modality of their choice, including preemptive transplantation. Similarly, the ESCO model does not include patients who have received a kidney transplant—a missed opportunity to increase access to transplantation and to best prepare transplant recipients who experience graft loss for a smooth and safe transition back to dialysis.
ASN believes that the optimal kidney care delivery model would eliminate these “silos” of care between advanced kidney disease, kidney failure/dialysis, and transplantation—and provide palliative care as needed throughout. Led by nephrologists, such a model would focus on managing and slowing the progression of kidney diseases and other complex chronic conditions kidney patients commonly face, and it would emphasize preparation for and management of care transitions with shared decision-making.
Creating continuity across the current silos of care delivery and payment for advanced kidney disease, kidney failure/dialysis, and transplantation would align the incentives in such a manner that health professionals and providers are rewarded for doing what is best for patients. For example, preventing a patient from needing dialysis for even a few months provides substantial savings, but currently health professionals are not rewarded for that optimal patient outcome. Similarly, transplantation is less expensive than dialysis over time and significantly improves patient outcomes, but under the current structure there is no mechanism to identify those savings and reward the health professionals who facilitate this process. A comprehensive kidney care model that spans the current payment silos would better align incentives to do the right thing for patients at each stage of their kidney disease.
As currently envisioned, patients would become eligible for the model at an estimated GFR of 30 mL/min/1.73 m2, and, unlike the ESCO and other proposed kidney care models (wherein patients are removed after receiving a kidney transplant), patients would never become ineligible for the model in the future. This ensures a smooth transition of care to transplantation and, if needed, back to dialysis, and it allows tracking the savings that result from a kidney transplantation.
ASN leaders are working through many questions on their way to developing a proposal for the P-TAC to consider. A topic of much consideration and debate is whether this model would best be developed as one that individual physicians could choose to participate in, or as a model that requires the participation of multiple stakeholders—building on the ESCO partnerships between dialysis organizations and nephrologists to include others, such as transplantation centers. Each approach offers upsides and downsides.
Regardless, moving from a conceptual model to an actual care delivery and payment plan to propose to the P-TAC is no small task. The ASN leadership will be working through a host of complicated questions and decision points in preparation for submission to the P-TAC. Your thoughts and input are welcomed: Please contact ASN Policy and Advocacy Specialist David L. White at firstname.lastname@example.org to share feedback.