Value-based care (VBC) is the buzzword in healthcare today, and nephrology is not behind in this venture. The word evokes anxiety and fear in most, as it is usually equated with a push to reduce costs by deploying expensive infrastructure, which comes with significant regulatory burden. What really happens is that the payor (insurance entity) delegates a subset of the population to a risk-bearing entity (RE) that has the skill set and resources to improve the quality of care provided at a lower than historical cost by use of innovative care models and technology. The financial savings (or losses) are then shared by the payor and RE. The patients in the program benefit from better quality and lower out-of-pocket costs. The end result is a win-win-win for all stakeholders.
After a successful 5-year pilot of the End-Stage Renal Disease (ESRD) Seamless Care Organization (ESCO), the Centers for Medicare & Medicaid Innovation (CMMI) launched the next generation of nephrology VBC models—Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC). Given that the Centers for Medicare & Medicaid Services (CMS) spends $121 billion per year on chronic kidney disease (CKD) with $84 billion going toward non-ESRD, it came as no surprise that these models expanded the population at risk by including CKD stages 4 and 5, correctly recognizing the need for intervention upstream to have a meaningful impact. Some payors are even experimenting with models that include CKD stage 3B.
Patient education and appropriate clinical interventions earlier in the course of disease are expected to slow the progression of CKD. At the same time, CMS recognized the need for the nephrologists to be the driver of these programs, aligning financial incentives. In a major shift from the ESCO pilot where the dialysis organizations created the RE, these new models task the nephrologist to launch the Kidney Contracting Entity (KCE), which mandates the inclusion of a transplant provider but makes the dialysis organization participation optional and by invitation only. In addition, the KCF models make it easier for the nephrologist to participate in a risk-free environment, providing financial incentives linked to quality metrics. The CMMI models are a precursor to an industrywide phenomenon with private payors exploring similar options.
Nephrologists are multidisciplinary team leaders in the dialysis unit and now have the opportunity to lead in VBC models for kidney care. This can be a great opportunity for nephrology practices to meaningfully change how we provide care to our patients. The thought of taking a risk may scare many of us and inhibit our opportunity to lead and in the process not only lose our autonomy and relevance but also the potential financial rewards.
To be successful during this transformation, a private nephrology practice must remain nimble, agile, and devoted to an ideology of enhanced patient outcomes at reduced cost. There are three basic keys to success in this new world.
Alignment and density: Alignment with like-minded nephrologists and physician collaboration becomes integral to the establishment of market density. Market density is important to implement programs that will improve the ability to care for large populations of patients in an efficient manner. CMMI allows for practices to join together in the CKCC model, pooling resources and reaching the required minimum number of patients.
Analytics capabilities: The ability to achieve target outcomes requires leveraging clinical data sets obtained from electronic health records, along with claims data. Analysis, strategic planning, implementation, and tracking become pivotal next steps for successfully managing the population at risk. Choosing a data-analytics partner who can provide this capability is an important step. There are a handful of vendors, mostly new entrants since the launch of the nephrology risk models, that have the knowledge and expertise in the nephrology space. Some focus only on the data, some on the care coordination, or both, whereas others offer a full suite of infrastructure and services, including practice management.
Infrastructure: The transition from fee-for-service (FFS) VBC does not require large capital outlay but does need a paradigm shift in how we think about providing care. A multidisciplinary approach with emphasis on patient education and engagement becomes the key to success. A nephrologist-led team of professionals is needed to perform the administrative tasks and implement operational best practices, clinical guidelines, and high-risk programs.
We truly believe that for the first time, nephrologists are in the driver's seat to lead the transformation of kidney care delivery. Although the ESCO focused only on ESRD patients, had high cost outlays, and did not align the financial incentive for the nephrologist, the new models represent a paradigm shift and provide up-front and risk-free financial incentives to the nephrologists who are linked to quality and outcomes. These include an increase in average reimbursement for CKD stages 4 and 5 patients from $400 per year (based on four office visits) to $800 per year (new capitated rate) (Figure 1), a kidney transplant bonus of $15,000 over 3 years, and a 5% alternative payment model (APM) bonus with the Merit-Based Incentive Payment System (MIPS) exemption (Table 1). Moving to the next level, a shared savings model can bring additional financial incentives but comes with a two-sided risk of sharing in losses.
We truly believe that for the first time, nephrologists are in the driver's seat to lead the transformation of kidney care delivery.
In conclusion, VBC models require us to think differently and provide an opportunity for the nephrologist to be the leader of transformation, but unlike history and prior models, this now represents a true investment in oneself.