Dallas Nephrology Associates’ Journey to Value-Based Care

ABSTRACT

Objectives: In 2016, Dallas Nephrology Associates recognized that the economic, humanistic, and societal burden of end-stage kidney disease was unsustainable and the fee-for-service model of reimbursement did not support a value-based care approach. We decided to be proactive by creating new workflows, education, and disease management so that patients could make well-informed choices, ultimately resulting in better outcomes.

Methods: Our shift toward value-based care focused on patient engagement, education, integrated infrastructure, collaboration, and monitoring of metrics associated with improved outcomes. Our practice invested millions of dollars in a population health division, which includes nurse navigators and data analysts focused on managing chronic kidney disease (CKD), delaying progression, and promoting transplantation and home-based dialysis.

Results: This retrospective review demonstrates improved outcomes, lower costs, and increased quality of care. Performance metrics have consistently met or exceeded targets. Seventy-three percent of patients now experience an optimal planned start to dialysis. Preemptive transplantation referrals have increased from 7% in 2017 to 61% through June 2023. Referral of patients with stage 4 CKD to educational workshops increased from 38% to 68%, and medical nutrition therapy referrals increased from 23% to 67%. Although reimbursement challenges persist, our commitment to improving care and slowing CKD progression remains steadfast. We emphasize teamwork, robust analytics, and continuous improvement. Future initiatives include encouraging patients receiving in-center hemodialysis to convert to home-based dialysis, addressing behavioral health, and focusing on preventable complications in high-risk patients.

Conclusions: By embracing value-based models, we have demonstrated that a patient-centered approach can lead to improved outcomes and value for payers.

Am J Manag Care. 2024;30(Spec. No. 13):SP999-SP1012

Approximately 14% of adults in the US have some degree of kidney disease, which disproportionally affects those with lower-than-average income and education.1 In 2020, the cost of managing these patients’ disease was approximately $23,770 per patient per year (PPPY), increasing to approximately $33,000 PPPY with disease progression.2 Although not all patients with chronic kidney disease (CKD) develop end-stage kidney disease (ESKD), according to the US Renal Data System, 807,920 patients required kidney replacement therapy in 2020.3 Spending on these patients was approximately $80,000 PPPY, accounting for 6.1% of all Medicare disbursement for 1% of Medicare patients.4

CKD progression can be slowed and replacement therapy delayed, which could save lives and money.5 Referring patients to a nephrologist early on allows for optimal management of disease progression and its complications. Nephrologists have experience in handling medications that can affect kidney function. Additionally, involving a nephrology team early ensures that patients receive appropriate education, empowering them to make better decisions about their care, ultimately leading to improved outcomes.5,6

The choice of replacement therapy for ESKD has an impact on outcomes and costs, with self-care therapies (eg, home dialysis) and transplantation being less costly. In 2020, the approximate PPPY cost of in-center hemodialysis (ICHD) was $96,000; peritoneal dialysis (PD) was $81,500; and a functioning kidney transplant was $40,000.4 Home hemodialysis is associated with superior patient survival compared with conventional ICHD or PD.7,8 Kidney transplantation is associated with better survival, higher quality of life, and lower costs than dialysis; however, the supply of donor organs is limited and not all patients are suitable transplant candidates.9 Importantly, patients who start dialysis as an emergency without adequate planning—referred to as “crash starts”—have worse outcomes, poorer quality of life, and higher costs than those who have an optimal start to treatment.10 An optimal start is defined as a planned dialysis initiation as an outpatient with permanent dialysis access, initiation of dialysis at home, or a preemptive transplant.

Generally, the care of patients with CKD or ESKD is reimbursed in fee-for-service models by private-payer insurance plans, Medicaid, and Medicare or Medicare Advantage plans. Regrettably, these fee-for-service models have done little to promote early referral or a coordinated holistic approach to the care of these patients. A more proactive and cost-saving solution exists in focused, protocol-driven case management of each patient that could be considered value-based care.

The goal is to have a system that pays for kidney health, not kidney failure. The current compensation model does not support the additional cost of the infrastructure necessary to be able to manage this population of patients. An outcome-focused alternative payment model that includes shared savings can provide the income required to better treat patients and improve outcomes.

Although attempts have been made to introduce a value-based approach to care (Figure 1),11-13 it is too early to assess whether these models will generate the improved outcomes and value they have promised. However, moving toward a more holistic, integrated, and preventive care model is a step in the right direction.

Founded in 1971, Dallas Nephrology Associates (DNA) was the first nephrology practice established in North Texas. DNA’s transition to a value-based care model began in 2016 before the Advancing American Kidney Health initiative was launched. Although outcome-based compensation models lag behind this approach, DNA believed that by operating a value-based care model, the practice could delay the onset of ESKD and better prepare patients for kidney replacement therapy. Herein, we describe DNA’s development of and transition to value-based care and we provide a summary of early outcomes.

METHODS

This retrospective review of real-world patient data and changes to clinical practice describes how we implemented improved pathways and transitioned our processes and infrastructures to focus on the best ways to generate optimal outcomes for patients (Figure 2). We added personnel to our team alongside our service development and actively engaged with primary care to develop strategies to comanage CKD as patients’ disease progresses. The evolution of value-based care at DNA consisted of 6 phases, outlined below and depicted in Figure 3.

Phase 1 (2016-2017): Introduction of Metrics and Value-Based Care

In 2016, DNA became 1 of 13 pioneer ESKD Seamless Care Organizations (ESCOs). Although the ESCO designation was focused on patients with ESKD, it was a stimulus for DNA to focus attention upstream on the care of patients with CKD stages 3 to 5. DNA standardized clinical workflows across all outpatient office practices. By doing so, data and metrics could be measured consistently and improvements could be tracked. DNA selected key metrics and measured baseline values, which included CKD education referrals, optimal dialysis initiation, referrals to transplant, and preemptive transplants. Communication with the providers and clinical staff began as care guidelines were developed. Scorecards were generated for each provider to measure progress toward achieving performance metrics.

Standardizing workflows involved implementing protocols and guidelines, which were expected to be used by providers who treat patients with CKD stages 3 to 5. We initiated a program of provider and staff education, which included basic concepts of population health management, value-based care, and the application of these to focus on outcomes.

Phase 2 (2018-2019): Value-Based Care

In 2018, our metrics expanded to include better preparation of patients and measurable adherence. There was a focus on visit intervals and practice guidelines for each stage of disease, enabling us to proactively manage patient cases and avoid crash dialysis starts at the hospital.

We focused on more accurately classifying patients by CKD stage using estimated glomerular filtration rate. We also started to measure the number of patients receiving treatment options education before starting dialysis, percentage of patients starting dialysis as an outpatient vs in hospital, percentage of patients starting dialysis with permanent access vs a temporary vascular catheter, and percentage of patients starting home-based dialysis. We also established mechanisms to measure the continued care of patients with ESKD, including transitions of care between the hospital and outpatient settings.

Phase 3 (2020-2021): Filling the Gaps/Nurse Navigators

Traditionally, nephrology practices rely on clinical staff to keep the outpatient office running efficiently. These staff also help manage cases of patients with CKD stages 3 to 5 by ensuring patients are scheduled to receive education and additional resources. As our involvement with these patients increased, it became apparent that a nurse navigator could assist with the management of these cases. After a pilot trial, this program was expanded to all offices.

Phase 4 (2021-2022): Population Management

In 2021, DNA was selected to participate in the ESRD Treatment Choices mandatory specialty care model. The evolution of our value-based care services continued at pace during this time with the creation of patient registries, including data on diagnosis and payer type. We also used these registries to evaluate DNA’s corporate performance and developed a corporate quality review reporting process.

Phase 5 (2022): Change Management

In 2022, DNA joined the first cohort of the voluntary Comprehensive Kidney Care Contracting (CKCC) option of the Kidney Care Choices (KCC) model. This enabled us to continue to benefit from total cost-of-care shared savings and losses on patients with CKD and ESKD covered by Medicare. Keys to success have been increasing our care navigation oversight, focusing on delaying the progression of CKD, identifying comorbid conditions, continuing our optimal start ESKD program, preventing hospitalizations, diverting patients from emergency department visits, and avoiding readmissions. Additionally, transparent reporting of metrics and adding incentives for providers helped them focus on clinically and financially important areas.

During this phase, we involved the multiprofessional team in discussions about potential enhancements or gaps in our services and developed plans based on the feedback we received.

Phase 6 (2023): Identify and Implement Wraparound Services

During the latest phase of our journey, we have been working with partners to identify additional services from which our patients might benefit. This includes behavioral health services, health coaches, interdisciplinary team attention from pharmacists and social workers, and home visits for high-risk patients. We have implemented enhanced workflows to ensure seamless service between DNA and any outside services. Continued focus on reinforcing education for providers and staff on value-based care initiatives was accomplished via performance metric reporting, in-person meetings, newsletters, podcasts, and live and recorded presentations.

RESULTS

Between 2017 and 2023, DNA’s population of patients with stage 4 or 5 CKD increased 9%. The vast majority of patients were 50 years or older. The percentage of patients 70 years or older increased steadily between 2017 and 2023. More than half of the patients were White; approximately one-fourth were Black. This distribution remained consistent during this time. The percentage of patients identifying as Hispanic or Latino increased slightly. There was a marked decrease in the percentage of patients covered by Medicare and more than a 2-fold increase in those covered by Medicare Advantage (eAppendix Table 1 [eAppendix available at ajmc.com]). We used billing data for a 3-year period (2021-2023) to identify patients with CKD and other comorbid conditions. Only 10% did not have any comorbidities; 50% had more than 2 comorbid conditions, such as diabetes or hypertension.

Six years into our value-based care journey, most of our quality metrics, including patient experience, cost of care (Table 1), and health outcomes have improved. Results from standard metrics continue to improve. We continuously review the data, looking at trends so that we can improve results with time. We have also changed data elements collected as we learn about the impact interventions have on the practice. Overall, 73% of new-initiation patients experience an optimal planned start to dialysis. Transplant referrals increased from 7% in 2017 to 61% through June 2023. Referral of patients with stage 4 CKD to educational workshops increased from 38% to 68%. Similarly, referrals of patients with stage 4 CKD to medical nutrition therapy increased from 23% to 67% (Table 2).

Patients who are educated by the nurse navigators demonstrate benefits such as improved engagement, higher likelihood of opting for home-based dialysis, and lower use of temporary venous catheters. There also is a notable reduction in no-shows compared with patients who have not participated in the program.14

We have not yet seen a marked increase in preemptive transplantation rates. The reasons may be multifactorial and could be due to the limited number of organs available for donation, time taken to evaluate living donors, and time taken to evaluate transplant recipients’ suitability.

DISCUSSION

This retrospective review of real-world patient data demonstrates how DNA’s transition to a value-based care model has improved the care of patients with CKD while also providing greater value to payers. The demographic and clinical characteristics of DNA’s patients are largely consistent with the general US population and reflective of the subpopulation of patients with kidney disease. The marked decrease in Medicare and increase in Medicare Advantage coverage can be explained by the 2021 changes in eligibility criteria. Before 2021, patients with ESKD were only eligible for Medicare parts A/B; thereafter, these patients became eligible for Medicare Advantage. The decline in transplant coverage was due to the 2020 transition from our pretransplant evaluation program to transplant hospitals that are now billing for these services.

In late 2020, CMS published all ESCO participants’ final 5-year performance results.15 Medicare sought to measure whether this model could reduce expenditures while maintaining or improving quality of care for patients with ESKD. Overall, in the US, there was a 3% decrease in the number of hospitalizations and a 0.4% increase in the number of outpatient dialysis sessions. This was achieved primarily by targeting patients at high risk of hospitalization and coordinating care to reduce avoidable hospital admissions. Over this 5-year period, the Dallas ESCO achieved cumulative shared savings of $21,719,188 (eAppendix Table 2).15

In 2021, DNA made the strategic decision to participate in the voluntary, total cost of care risk Center for Medicare and Medicaid Innovation CKCC model. This model’s goals are to delay and improve initiation of dialysis in patients with late-stage CKD, improve coordination of care to reduce the total cost of care, increase the number of kidney transplants, and increase options for provider risk and payment to improve financial accountability. The financial results for performance year 1 under this model were recently published.16

Changing the focus of nephrology care from a disjointed and siloed fee-for-service model to a more patient-focused approach has improved outcomes and delivered value for all payers. DNA has built a service based on the principles of preventive care, involving and educating patients at every stage to minimize unplanned or emergency episodes.

The Population Health Division of DNA was established to provide central care coordination, vision, and oversight. Responsibility is focused on guiding and transforming the practice for successful participation in value-based care models for risk-share contracting from government and private-payer initiatives. The team is led by a chief innovation officer and supported by administrative leadership, value-based care analysts, clinical nurse managers, and other dedicated practice resources. Together, they develop protocols, guidelines, workflows, data analytic measurement tools, and information technology infrastructure capabilities to facilitate transformation of the practice.

At the core of our operation are the registries we created for each patient cohort. These track, monitor, and measure against established quality and financial benchmarks. Our dedicated analytics team provides regular reports to support transparency and an understanding of performance against established benchmarks. Embedding analytics within our practice is essential to support continuous improvement.

DNA’s nurse navigator care coordination was launched in 2020. We recruited 12 nurses to manage cases of patients with CKD stage 4 or 5 at every DNA office. These nurses work closely with physicians, directly interacting with patients to ensure they have access to the support and services to help delay disease progression. They engage patients and their families in an education program of 7 CKD workshops to help them understand their disease, available treatment options, and the social and psychological implications of living with kidney failure. This program is available in English and Spanish and is supported by a team of registered dietitians who help patients understand the importance of diet and fluid intake to reduce complications and slow disease progression.

For patients who eventually progress to ESKD, nurse navigators support the transplant application process, assist with dialysis choices, and refer patients to surgeons for dialysis access placement. Nurse navigators are fundamental to tracking value-based metrics, patients’ progress, and DNA guideline implementation.

A centralized dialysis placement team works closely with patients, discharging providers, and hospital case managers to ensure that patients receiving in-center and home-based dialysis have their cases managed in the most appropriate setting and as close to where they live as possible.

The transition-of-care management team’s objective is to reduce hospital readmissions and emergency department visits. They are notified when a patient is discharged from the hospital, and they contact the patient to schedule a transition-of-care visit in our offices within 7 days of discharge. The team is responsible for obtaining hospital records and making them available to physicians to facilitate the continuity of care after discharge.

Our skilled nursing facility and rehabilitation services enhance collaboration, communication, and care coordination across our organization, providing continuity of care from acute to postacute care.

Finally, the specialist services of supportive and palliative care ensure the alignment of treatment plans for patients and their families. These services value, honor, and respect the decisions made by patients throughout their entire journey with kidney disease care. They allow patients to choose active medical management without dialysis or a transplant while remaining engaged with their nephrology provider.

To date, DNA has invested several millions of dollars in personnel and systems. This investment has focused on 3 key components: population health management, robust analytics, and our nurse navigators. These teams work with a dialysis placement team, transition-of-care team, skilled nursing and rehabilitation service, and palliative care. There is continued commitment to funding this infrastructure to remain successful. However, these costs have not been covered by any payer arrangement because the majority of patients with CKD in our care are not included in the KCC model and are paid for by private insurers on a fee-for-service basis. In addition, the shared savings have not yet offset the up-front costs.

We believe our success, although multifactorial, has teamwork at its heart. Everyone at DNA works together and focuses on the same goal. We collect data that inform ongoing continuous improvements in outcomes across the organization and have improved our data collection as our service has developed. This systemwide approach considers the whole patient throughout their life. Through our nurse navigator care coordination, we have been able to align all services. Improving patient understanding of their kidney disease through education helps engage and encourage them to take control of their health and has shown great promise. Communication is fundamental to our approach and is underpinned by robust analytics and regular review of important metrics.

We realize that none of this would be possible without communication and coordination with patients’ primary care providers. We are intentionally focusing on improvements in this area and eliminating information silos so we can work together as a seamless health care team on behalf of these complex patients.

The size of DNA has afforded economies of scale. Inevitably, some patients incur more health care costs than others; thus, having a large number of patients can minimize financial risks. However, we have implemented this system largely within the confines of the fee-for-service model because the care for the majority of our patients with CKD is reimbursed through third-party payers, including Medicare. The ongoing rhetoric about value-based infrastructure has promised much, but to date, there have been no significant steps forward to pay for these achievements. Our ultimate goal is to participate in alternative payment models that include shared savings for providers.

Our ambition is to slow the progression of CKD and delay the need for renal replacement therapy. We are developing outreach services and intensive care management for high-risk patients. Increasing our focus on behavioral health and the social determinants of health will improve outcomes for those most at risk of kidney disease. Slowing the progression of CKD goes hand in hand with focusing on preventable complications that commonly affect this patient group, including peripheral vascular disease, leg ulcers, coronary artery disease, and congestive heart failure. This will form a central part of the next stage of our journey.

Acknowledgments

The authors would like to thank Janet Wild, PGCME, on behalf of The Write Source MSC, for medical writing assistance, which was funded by Dallas Nephrology Associates.

Author Affiliations: Dallas Nephrology Associates (BT, PS, ME, LP, MS, AL), Dallas, TX.

Source of Funding: None.

Author Disclosures: Ms Tommey is executive director at Dallas Nephrology Associates (DNA) and serves as a consultant or paid adviser for Texas Kidney Solutions (an LLC that provides value-based care consulting for nephrology practices and is 50% owned by DNA). Dr Skluzacek is employed by and on the board of directors at DNA and is medical director for the Dallas Kidney Care Entity; he also serves as consultant or paid advisor for Texas Kidney Solutions. Ms Echols is population health director at DNA and serves as a consultant or paid adviser for Texas Kidney Solutions. Dr Liang is president and CEO at DNA, is a member of the Renal Physicians Association, and serves as a consultant or paid advisor for Texas Kidney Solutions. Mrs Phelps is director of clinical operations and chief nursing officer at DNA and serves as a consultant or paid advisor for Texas Kidney Solutions. Ms Shew reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (BT, PS, ME, LP, MS, AL); acquisition of data (BT, PS, ME, LP, MS, AL); analysis and interpretation of data (BT, PS, ME, LP, MS, AL); drafting of the manuscript (BT, PS, ME, LP, MS, AL); critical revision of the manuscript for important intellectual content (BT, PS, ME, LP, MS, AL); administrative, technical, or logistic support (BT, PS, ME, LP, MS, AL); and supervision (BT, PS, ME, LP, MS, AL).

Send Correspondence to: Belinda Tommey, MHA, Dallas Nephrology Associates, 1505 LBJ Freeway, Dallas, TX 75234. Email: tommeyb@dneph.com.

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