Value-Based Payment Models Aim to Boost Patient-Centered Care

Bridget M. Kuehn
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It takes a multidisciplinary team, including a nurse coordinator, psychologist, and pharmacist, to successfully run the Kidney Care First (KCF) program at The University of Alabama at Birmingham (UAB). The program’s lead nephrologist, Gaurav Jain, MD, a professor and associate division director of nephrology at UAB, described his experience during a Kidney Week 2022 session entitled, “Value-Based Payment Models Generating New Approaches to Kidney Disease Care.” Jain and his colleagues chose to join the Centers for Medicare & Medicaid Services’ (CMS’) KCF value-based payment model (1) because they hoped it could decrease the cost of care and help boost patient transplant rates. Although assessing such outcomes will take more time, Jain said the program has already been rewarding and allowed him to access additional patient care resources. “It’s a small program, but it gives me a lot of joy,” he said. “It’ll definitely make patients’ lives better.”

The KCF program and the Comprehensive Kidney Care Contracting (CKCC) options are part of the latest evolution of value-based payment models for kidney care, along with the mandatory ESRD Treatment Choices (ETC) model. CMS designed the programs to incentivize nephrology practices to improve care for patients with late-stage chronic kidney disease (CKD) or kidney failure, also known as end stage kidney disease (ESKD). Panelists at the Kidney Week session discussed what it is like to participate and how these new payment models have changed from earlier versions.

Misaligned incentives

Panelist Daniel Weiner, MD, MS, highlighted the evolution of value-based payment models in nephrology and the need to better align incentives with the program’s goals. He noted that nephrology’s “moonshot” came 50 years ago when in 1972 amendments to the Social Security Act extended Medicare coverage to patients with kidney failure (2). Weiner said that approximately 10,000 people at that time in the United States were receiving dialysis through a “hodgepodge” of programs funded by foundations or the Veterans Health Administration, but many patients did not have access to the treatments. “We got access for as many people—or almost as many people—in this country who needed a life-saving treatment,” he said. But challenges and barriers to access remain, he noted.

One of those challenges has been the high cost of providing care for those with kidney failure. CMS pays approximately $50 billion yearly on the care of people with kidney failure or approximately 7% of Medicare’s budget, comprised of $37 billion through traditional fee-for-service spending and $13 billion through Medicare Advantage in 2020. “Health care is the largest expenditure by the U.S. government, and dialysis is one of the largest line items in that expenditure,” Weiner said. Of the $37 billion in fee-for-service spending on people with kidney failure in 2020, $12.6 billion was spent on outpatient dialysis.

CMS has created a series of value-based care initiatives to reduce costs while promoting the best possible care. The first was a “bundle” or pay-for-performance program mandated by the Medicare Improvements for Patients and Providers Act of 2008 for dialysis providers (3). Weiner noted, however, that CMS paid physicians under a separate monthly capitation program. “We actually get paid much better for caring for people who are receiving dialysis than we do for keeping somebody from needing dialysis,” he said. “That’s a misaligned incentive.”

The Comprehensive End-Stage Renal Disease (ESRD) Care Model (4) created accountable care organizations for patients with kidney failure who shared the cost savings and losses with CMS based on quality measures. It incentivized the organizations to keep patients out of hospitals and as healthy as possible. Weiner noted that it included the use of patient navigators and patient advisory committees, but the program only included patients with kidney failure. There was a misaligned incentive because patients receiving a transplant—often among the healthiest patients at a dialysis organization—could hurt the organization’s bottom line, he said.

More recent policy developments, such as the 2019 Advancing American Kidney Health initiative (5), aim to reduce the number of U.S. individuals developing kidney failure by 25% by 2030, substantially increase the number receiving home dialysis by 2025, and double the number of kidneys available for transplant by 2030, Weiner noted. Newer, value-based care programs, such as the ETC model, have also added incentives to increase the number of patients on transplant lists and the number of patients on home dialysis, he said. But, he said, the pandemic and current staffing shortages make assessing their effects difficult. He worried that using transplant wait lists versus transplants might create misaligned incentives. “The key thing here is that it doesn’t move upstream,” he said.

He acknowledged that the fragmented nature of the U.S. health care system makes continuity of care for patients with chronic health conditions difficult. There are separate “silos” for care of kidney diseases, dialysis, and transplant care. Too often, patients in the early stages of kidney diseases go undetected because of a lack of screening for kidney diseases. “We’re not screening adequately for albuminuria, and by the time people get to us, it is too late,” he said. “We have to move much farther upstream.”

Team-based care

The KCF model builds on the ETC model, according to CMS. To participate, Jain said a practice must have at least one nephrologist with approximately 200 patients with ESKD and at least 350 patients with stage 4 or 5 kidney disease. Smaller practices, he noted, can team up with other practice partners. He and his colleagues have teamed up with Banner Health in Phoenix, AZ, and the University of California, Los Angeles (UCLA).

The practices get an extra $35 monthly for each patient on home dialysis in addition to their monthly capitation payment, Jain said. They get a quarterly capitated payment for patients with advanced CKD equivalent to what they would get paid for patients on dialysis. The financial “backbone” of the program is a $15,000 bonus paid over 3 years for every patient who receives and maintains a transplant, Jain said. He said there is also a performance-based adjustment to the payments based on a predetermined set of quality metrics.

Session speaker Dylan Steer, MD, a nephrologist at the Balboa Nephrology Medical Group in La Jolla, CA, said the CKCC is an accountable care organization model that uses the same quality metrics as the KCF program. Participating organizations still get capitation payments but also share in Medicare cost savings or losses. The program has three shared savings options: graduated, 50%, or 100%. He noted that participation in the first cohort of CKCC has been high, with approximately 2400 aligned nephrologists and 200 transplant providers participating. Additionally, approximately 63,000 patients with kidney diseases and 54,000 patients with kidney failure receive care through one of the participating organizations. Patient activation is one of the key quality measures in both CKCC and KCF. Other quality measures include optimal kidney failure starts and depression remission, Steer said.

Patients must complete surveys assessing their activation every 6 months. The survey asks patients questions, such as whether they feel competent to carry out their medical treatments at home, if they are experiencing mental illness symptoms, or if they know what each medication does. It is often the first time that a patient has been asked these types of questions, Jain said, and it creates an opportunity to intervene. Steer said he was initially skeptical of the patient activation surveys but that the patient feedback has been very positive.

Steer and Jain emphasized the need for an upfront investment to succeed in either program. Jain’s team includes a full-time registered nurse coordinator. There is also a nephropsychology clinic staffed one-half day each week by a psychologist who sees all of the program’s patients. The psychologist helps talk with patients about the importance of sleep and medication compliance, helps patients with depression, or addresses the concerns of patients who are afraid to start dialysis. A pharmacist from Auburn University also works with patients 1 day each week, goes through patients’ medications, and helps them troubleshoot. Jain also works with DaVita’s CKD Insights program, which pulls all the CKD patient data into a platform that allows a patient navigator to identify patients who may be at risk for hospitalization or who need dialysis education or a dialysis access procedure. Jain said it is also essential to get help running the program’s business and informatics side and to set aside enough time for the lead physician working in the program. “The nephrologists need to be at the center of the care,” he said.

Jain emphasized the importance of choosing the right partners: “Find someone who is similar minded and similar sized and talk with [him or her] and assess [him or her].” He noted that he and his colleagues at Banner Health and UCLA have learned from each other.

Steer also emphasized the importance of picking the right partners, making sure participating nephrologists have dedicated time for the program, and working with the onsite team to troubleshoot as issues arise. He acknowledged that starting a value-based care program can be daunting but can also help to better align an institution’s values with the care it provides. “You don’t have to be perfect; just better,” Steer concluded.