Dr Daniel Weiner Reviews Benefits, Challenges of Value-Based Payment Models for Chronic Kidney Disease

There are several shortcomings with current value-based payment models available for the management of chronic kidney disease (CKD), but some incentives, such as the Kidney Transplant Bonus, show the potential benefits of a pay it forward approach that can be impactful for other sectors of health care, said Daniel E. Weiner, MD, MS, board certified nephrologist and lead navigator at Tufts Clinical and Translational Science Institute.

Weiner spoke during a session at the American Society of Nephrology (ASN) Kidney Week 2022 meeting titled, “Push the Right Buttons for Better Kidney Disease Care: Value-Based Models.”

Transcript

Can you speak on benefits and challenges of the value-based payment models available for CKD that you will address during your session at Kidney Week 2022?

I think I’ll first sort of mention the shortcomings of it. [For] the value-based payment models, most of the ones that exist are all based on Medicare fee-for-service (FFS), which, until recently actually [covered] the majority of patients on dialysis, the vast majority of patients on dialysis—that's not the case anymore.

You have this huge movement to Medicare Advantage and now it's a minority of patients on dialysis that are Medicare FFS. So, the models, I think that were very well intentioned, are only getting a very small proportion of the population. And so I don't know how successful they'll be, because the vast majority of people are not going to be Medicare FFS in 1, 2, 5, 8 years. So, you're missing an opportunity here to change things.

I think the other big factor with that is when people are doing Medicare Advantage or other payers, they bounce around from payer to payer. So, an individual payer doesn't have the same incentives to prevent people from progressing. If you have good metrics in place, they may have incentives there to be able to do that, but if it's going to cost a lot of money to prevent something that can be somebody else's problem later on from a payer perspective, you have some misalignment there. And we know that people change payers exceptionally frequently. So, that's a really difficult thing.

That stated, the models actually are pretty interesting, and you can broadly divide them up into 2 sets. There's the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model, which is a mandatory model, and there's the Kidney Care Choices (KCC) Models, which are voluntary models. ETC only applies to patients on dialysis and I think it may be limited ultimately in what it accomplishes. It uses pretty much a brute force approach to push more people onto the transplant waiting list and into home dialysis.

These are good things, but it's a fairly brute force model with pretty heavy risk and pretty heavy downside for nephrologists and dialysis units. Critically, it also doesn't expand silos—it's locked into the dialysis silo, in some senses it’s reinforcing that.

The much more interesting models are the ones in the KCC program and those are voluntary models. I think the most exciting thing there, particularly philosophically, is something called the Kidney Transplant Bonus. So, this is an up to $15,000 bonus that gets paid out over 3 years if a beneficiary who's within one of these programs gets a kidney transplant.

The interesting thing is that the kidney transplant recipient oftentimes isn't going to be cared for by the nephrologist who’s in the model. So, it really speaks towards success, making sure that patients are informed, that they're in the best possible shape to get the transplant, that you are promoting this transplant process.

It will still count even if it's a preemptive transplant, and it's a way of getting around the fact that care systems are going to change, but what you do 3 years earlier still can have tremendous impacts down the road. And I just thought that was incredibly clever and it's really incentivizing the right way. It's incentivizing investment at an earlier time point for a huge payoff for the patients later on. And I haven't seen that too much in other models where it's taking this sort of long approach.

I think that has relevance elsewhere in the health care system, and I'm not smart enough to figure out how to design this, but if you can develop systems where people are paying it forward, regardless of if they're changing health insurers or changing providers, so on and so forth, but where care that is done now that will impact beneficially a patient and their families years from now, there's some reward for the care that's done now. I think if we can design a system like that, that would be huge.

It'll take a lot because you're overcoming this fragmented US health care system. And people from Canada or other places laugh at us when we talk about these things, because it's like, well, of course, single payer, we can pay things forward. It's not going to happen in the United States, but if we can figure out a way to cross that different type of silo, and really incentivize the right thing now, when it has a 5-year benefit or a 10-year benefit, that would be a huge innovation, and we're not there yet.