Kidney care in the United States is undergoing a rapid transformation as the primary payer, Medicare, moves from volume-based, fee-for-service payment systems to value-based payment systems. Nearly 50% of current CMS payments are based on value delivered, and by 2020 this is likely to be over 90%.
The ESRD program has been at the forefront of these changes because of its heavy dependence on Medicare as a primary payer, its unique position as a disease-specific entitlement, and the high clinical complexity and cost of the patient population. Together, these circumstances create a great opportunity for the discipline of nephrology and all nephrologists to help shape care delivery and payment for kidney patients as well as other complex chronically ill populations, creating significant improvements in patient outcomes, while responsibly stewarding resources. There are a number of challenges in the coming year from the perspective of dialysis provider chief medical officers (CMOs).
➊ Transformation of the health care system and transformation of the practice of nephrology
There is no question that systemwide transformation is occurring in the US and globally in the view of providers and payers for healthcare. The movement from volume to value, whereby providers are increasingly accountable for clinical outcomes as well as the total costs of care, is occurring rapidly.
Nephrologists need to be leaders in this new healthcare world and to be successful will need to understand the principles of population management as well as the specific clinical management and care coordination needs of individual patients. Although in the past this evolution of the practice of medicine was like the unicorn—frequently spoken about but rarely seen—it is now clearly happening in nephrology and nephrologists need to be prepared to lead programs and systems of care to ensure the best outcomes for kidney patients.
➋ Where do nephrologists and dialysis providers fit in the new healthcare system?
Nephrologists and dialysis providers will be at the forefront of the new healthcare system owing to the disproportionate cost of advanced CKD and ESRD patients. Innovative solutions for improving care and controlling costs will be needed going forward. Nephrologists and dialysis providers will need to work together to ensure that these solutions are identified, tested, and implemented.
Nephrologists in the future will have more options regarding their clinical work environment, with an increasing number likely to find salaried positions with health systems, integrated health care organizations, physician groups, hospitals, or dialysis providers. Career counseling needs to be broadened to inform nephrologists of the benefits and pitfalls of these options. In addition, integral to the success of integrated care is the ability to seamlessly share patient information through electronic health records. Nephrologists need to work closely with other providers to design more usable systems and algorithms to enhance such sharing of information in a real-time fashion.
➌ The nephrology workforce
The care of patients with CKD and ESRD will be dependent on teams of individuals, including, but not limited to, nurses (RNs and nurse practitioners), social workers, care coordinators, patient care navigators, health coaches, patient care technicians, clinical specialists (e.g., podiatrists, cardiologists, endocrinologists, vascular surgeons), insurance/benefits experts, and others who focus on the social determinants of health, such as housing, nutrition, transportation, and employment. The nephrologist needs to be the leader and coordinator of this team.
There is considerable concern that the decrease in matched Fellows and increase in international medical graduates (IMGs) will make it difficult to achieve sufficient numbers and quality of nephrologists in the future to meet the needs spanning clinical and administrative functions. It is our hope that interest in the practice of nephrology will increase as the role of the nephrologist changes.
➍ Integrated care and the ideal role of the nephrologist
It is useful to think about the role of the nephrologist caring for CKD/ESRD patients from the perspective of the site of focus of care.
In the dialysis facility, nephrologists serve as the population health leader when acting as a facility medical director. In addition, nephrologists play an additional role as the principal care provider for each patient for whom he or she is responsible. This role is distinct from primary care, and training programs need to educate nephrologists on these distinctions including roles and responsibilities for each.
Outside the dialysis facility, nephrologists are now likely to be even more involved in care coordination, particularly with the new Quality Payment Program (QPP), which incentivizes participation in care coordination. The QPP, the outgrowth of the Medicare Access and CHIP Reauthorization Act, provides an opportunity for nephrologists to align financial incentives with clinical imperatives. It is essential for nephrologists to understand the impact of nontraditional co-existing diseases so prevalent in kidney patients, as well as the effects of conditions or social circumstances on the health outcomes of the kidney patient. This requires the nephrologist to be more involved in the overall assessment and care of patients, serving as the principal care physician.
➎ Influence of regulatory oversight and public data on patient care
There is extensive literature on the impact of publicly reported health outcomes (PROMs) on physician behavior and quality of care. Clearly the results are mixed, and few data are available in nephrology. There is a need for increasing rigor in the development and selection of quality metrics to be used in such systems so that the unintended consequence of judging quality on irrelevant metrics does not drive resources to be devoted to things that don’t really impact quality of patient care.
While such oversight of quality in the payment system through the Quality Improvement Program (QIP) has been one of the primary approaches by CMS, further refinement of measures and methodology used to calculate the QIP measures needs to be informed by evidence, sound methods, and in the future include PROMs. Continued engagement of the nephrology community in such accountability systems is essential. Finally, accountability of nephrologists should also be an area developed and structured through the discipline, not by regulators.
➏ How evolution of the ESRD prospective payment system affects innovation in the kidney space
There is no question that the introduction of the bundled payment system has had a chilling effect on pharmaceutical and device innovation for kidney patients. Uncertainty about reimbursement potential for new products fosters reluctance for commercial entities to invest. Of note, however, is the more recent renewal of interest in innovation as integrated care systems for kidney patients grow. In such settings, any innovation that creates value generates interest. For example, a more expensive dialyzer is a valuable investment in an integrated care setting if the result is a healthier patient who lives longer and does not require hospitalization. Manufacturers understand this and are starting to react slowly. Removing regulatory barriers to innovation is an important driver of innovation for the future. An assessment of the clinical trials and technology advancement in therapies and pharma would help provide data to assess the question of recent innovation or lack thereof.
➐ Improving care for patients with CKD
Few patients with advanced CKD (GFR <45 mL/min/1.73 m2) even know they have kidney disease. Currently, there is not a systematic approach to population health for patients with CKD. Nephrologists and other providers should work together to develop new, improved approaches for care for patients with CKD.
➑ Increasing access to kidney transplant
Most agree that transplant is the optimal therapy for patients with kidney failure. Yet few patients benefit from a transplant: only 2.6% of patients with kidney failure receive a preemptive transplant as a treatment; the remaining 97.4% start dialysis. Nephrologists and other providers should work together to develop new approaches to improve access to kidney transplantation.
➒ Improving end-of-life care
Patients >80 years old with multiple co-morbidities have comparable outcomes if they receive comprehensive conservative care instead of dialysis, yet few choose this option. One of the barriers to improving access to non-dialytic care for those who might benefit more from an aggressive medical approach to their uremia, rather than from dialysis, is the lack of training in non-dialytic care. In addition, patients on dialysis at the end of life utilize hospice much less frequently than other patients with similar co-morbidities and cost of care. Nephrologists and other providers should work together to improve end-of-life care, both for patients with CKD and patients on dialysis. ASN could explore curricula elements that inform nephrology trainees about medical strategies that extend the duration and quality of life without dialysis.
➓ Improving access to home dialysis
Most nephrologists and clinicians would choose home dialysis for themselves, yet few patients on dialysis are able to benefit from dialysis at home. A patient dialyzing at home has more autonomy, is more likely to continue to work, and has more satisfaction in their kidney care. Many training programs do not have a sufficiently large home dialysis program to adequately train fellows. They therefore have difficulty recognizing appropriate candidates for home modalities and do not feel comfortable prescribing home dialysis when they get into practice. Nephrologists and other providers should work together to identify opportunities to make it more likely that patients on dialysis can benefit from home dialysis, including rethinking curriculum structure and requirements for training and competence in home dialysis.
The year 2017 holds a number of challenges and opportunities for kidney health care providers. In this pair of articles, ASN President Eleanor Lederer, MD, FASN, and leading US dialysis organization CMOs take a look at the state of kidney care at the end of 2016 and where we are headed in 2017 and beyond.
