Value-Based Frameworks Can Help Transform Kidney Care Delivery

Kidney care is characterized by complex patient needs that create high risk for payers and providers. Managing this risk while optimizing patient outcomes cannot be achieved with traditional fee-for-service (FFS) models, with public and private payers largely transitioning to the adoption of value-based care programs, noted Terry Ketchersid, MD, MBA, senior vice president and chief medical offficer, Integrated Care Group, Fresenius Medical Care, during a session at AHIP 2022.

Described by Ketchersid as the current focus of value-based care, kidney disease, specifically end-stage renal disease (ESRD), affects 1% of the Medicare population, yet these patients consume approximately 7% of the budget. His organization has been involved in value-based care for over 15 years and is affiliated with 20 of the 55 risk arrangement models operating today by the Center for Medicare and Medicaid Innovation (CMMI) for the management of ESRD and chronic kidney disease (CKD).

“Those kinds of differentials direct attention. And what CMMI is trying to answer with all these models is a simple question: Are these patients different enough that they need their own payment model? And if that answer is yes, the way providers who care for patients who have ESRD will get paid may be different,” said Ketchersid.

Adding that these patient populations are indeed different than the general population, he said that the complex care needs for kidney disease warrant different solutions than those typically provided in a transactional FFS model.

​​”When these value-based care models are put together appropriately, both the payers' and the providers' interests are aligned, and the winner is ultimately the patient, because in these value-based care models, we can actually buy things for patients that we cannot afford in a transactional FFS environment,” he explained. “As a company invested in things that ordinarily you'd think, 'Well, wait a minute, as a for-profit health care company, there's not a return on investment here,' in value-based care, there is.”

Chief among these investments is the importance of preventive care, which proves particularly effective in kidney disease. An estimated 100,000 people with ESRD are on the waitlist for needed kidney transplants, but due to the high mortality rate associated with advanced kidney disease, Ketchersid said many will die before a kidney becomes available.

Finding creative solutions through value-based programs to address the kidney transplant supply-and-demand bottleneck has been difficult for payers, he said. Efforts made by his organization have sought to leverage living donors related to the patient by working with several programs that have shown benefits, particularly in underserved communities, on educating patients about the implications of their genetic connection.

“A part of the problem is even though [transplant] is the best outcome for the patient, and even though long term the total cost of care is substantially lower, the up-front cost of actually doing a transplant is off the charts. So, we're going to continue to do the things that need to be done and continue to work collaboratively with payers to try and find a way to include that whole transplant aspect in the value-based care space.”

As a majority of Medicare projects exclusively include patients with late-stage kidney disease, he added that expanding criteria to those with CKD or other conditions, such as diabetes and hypertension, in value-based care arrangements can reduce risk of progression and lead to cost savings. An estimated 99% of those with ESRD initially present with these comorbidities, and providing access to standardized kidney disease education, as well as ensuring those who go on dialysis have adequate advanced care plans and shared decision-making can lead to improved patient outcomes.

“The transition from late stage CKD to ESRD is one of the most broken transitions there is in medicine today. Largely, because of the incentives created by FFS,” Ketchersid explained.

“One of the things we can do is in markets where we have geographic concentration, we can put a licensed individual embedded in the nephrologist practice, and their job is not to try to figure out how to generate an FFS claim—their job is to get up every morning and think about how to impact in a positive way the decisions that patients can make when they're not in the office. In our experience, when we do that, wonderful things happen, outcomes improve, and costs go down.”

Ketchersid said that moving forward nephrologists and those involved in kidney care delivery will have to be knowledgable on the full care continuum from early stages of CKD to dialysis. Additionally, the need for care models to be certified by certain regulatory organizations was cited, as payers’ delegation of risk to providers in value-based contracting will require assurance that the return on investment is achievable.