Nephrology Director Shares Ups, Downs of Participating in Kidney Care First

In 2019, HHS announced an overhaul of how kidney care is delivered and paid for in the United States in an effort to better align incentives and outcomes for Medicare beneficiaries.

The Advancing American Kidney Health initiative set forth 3 goals: a 25% decrease in kidney failure incidence by 2030; shifting to home dialysis or transplant for up to 80% of patients with end-stage kidney disease (ESKD) by the end of 2025; and doubling the available kidneys for transplant by 2030.

At a Saturday session at Kidney Week 2022, the associate division director of nephrology at the University of Alabama at Birmingham (UAB) described his organization’s participation in Kidney Care First (KCF), 1 of the 4 available models.

Guarav Jain, MD, FASN, described how UAB decided to join, what lessons they learned, and the successes and challenges they have experienced. Jain also co-leads the Alabama Physician Network, the accountable care organization (ACO) within the UAB health system.

Having experience and a strong belief in value-based care is necessary, he said. “This just made inherent sense to us,” he said.

The leadership above him was supportive and on board, even though he told them up front the model would not generate instant, generous profits.

The KCF model must include at least 1 nephrologist and a nephrology group practice, with 50% of the revenue coming from nephrology services. After performance year 1, CMS will allow other advanced care practitioners, such as physician assistants and advanced nurse practitioners, to join.

There must be at least 200 patients with end-stage renal disease (ESRD) and 350 with stage 4 or 5 CKD.

When the KCF was first announced, it was initially targeted at smaller practices, but to widen the pool of those considering applying, CMS now allows multiple practices to partner for the purpose of aggregating their beneficiary counts.

Monthly payments are capitated for ESRD, and there are quarterly capitated payments for CKD. To encourage home dialysis, there is a “true up” payment of $35 per beneficiary.

A key part of the model is that it offers a transplant bonus of $15,000, paid over 3 years, “which, frankly, is financially the backbone of this program.”

One of the challenges, he said were the model’s quality measures, and the first one is called a “gateway” because it literally is a gateway - not passing it means an automatic financial penalty

The quality gateway calls for, by 12 months, improvement in the Depression Remission metric, and gains in patient activation as measured by a 13-item patient questionnaire called the Patient Activation Measure (PAM). The PAM must be administered at least twice, 6 months apart, to at least 50% of the beneficiaries in the program.

The short time to show improvement in PAM is not its only challenge, he said. It hasn’t been validated in patients with CKD, although it has in some other chronic diseases, and it takes administrative time.

The utilization measure includes Optimal ESKD Starts (home dialysis, kidney-replacement therapy with a pre-emptive transplant, or, if using center-based dialysis, using an arteriovenous fistula or a peritoneal dialysis catheter) and the total per capita cost of care.

Another big challenge is communicating with CMS, which, he said, has no assigned teams to communicate with about KCF, including no dedicated phone number, and it may take 2 to 4 weeks to get an email returned, often without an answer. Replying to the email sets off another weeks-long wait time.

“This is not what we are used to,” he said, to some chuckles from the audience. "You know, in academics, if you write an elaborate email, you get an elaborate email back.”

In thinking about whether KCF is a good fit, he said, practices have to ask themselves many questions, such as:

• What is their experience with other forms of value-based care (Medicare Advantage, ACOs)?
• Do they have the workflow?
• What is their market like?
• Do they have existing partners?
• Who will take the financial risk?
• What are the upfront costs, and can they create the team that is required to run it?

Jain credited the clinical care coordinator and the rest of the multidisciplinary team, including a pharmacist and a psychologist, for the success of the program, as well as the leadership at the university, which, he said, agreed to do it because it was the right thing to do for patients.

In the best-case scenario, he said, he expects the program will make $1.5 million by the third year.