Global Risk: Where Primary Care Moved, Nephrology Is Headed

Author : Strive Health

The start of 2022 marked the launch of the Centers for Medicare and Medicaid Services (CMS) long-delayed Kidney Care Choices (KCC) model — the first nephrology-centric value-based payment model. The KCC models, called Comprehensive Kidney Care Contracting (CKCC) and Kidney Care First (KCF), center nephrologists as leaders of their patients’ kidney care and create a foundation for these providers to take on risk.

KCC offers participants the chance to engage in varying payment and risk-sharing options — from more traditional outcomes-based payments to tiered shared risk arrangements.

If the evolution we’ve already witnessed in value-based kidney care models is any indication — and if primary care offers any lessons — it stands to reason that kidney care is headed for industry-wide global risk contracts for nephrology practices.

What is global risk? 

Global risk, also known as full risk, occurs when provider organizations take on 100% of the risk related to patient outcomes and total cost of care. These models emphasize whole-patient care and payment for positive patient outcomes. If successful, participating providers have the potential to access significant financial upside.

The current “risk” state for kidney care and what’s to come

Currently, value-based contracts in kidney care are payor- or dialysis center-led. Payors contract with value-based care organizations to cover their membership broadly. Nephrologists have not been meaningfully included in these contracts and are largely excluded from driving care delivery decision-making. Additionally, their financial opportunities are largely restricted to activity-specific quality bonuses, severely limiting their upside potential.

However, regulatory changes over the last few years have spurred a shift in mindset around these models. The 21st Century Cures Act opened full-risk Medicare Advantage plans to ESKD patients, creating expectations of a significant rise in Medicare Advantage enrollment. Payors are now looking to shift risk on these highly specialized and costly patients to providers who understand how to effectively manage them – namely nephrologists. Nephrologists control key levers to reduce these patients’ cost of care and have been increasingly investing in practice resources and capabilities to serve these populations better.

In the coming global risk world, nephrologists will be at the center of full risk contracts for CKD and ESKD members and will drive attribution of these patients. Given these changing dynamics, nephrologists will finally have a seat at the contracting table and access significant financial upside and growth potential.

Lessons to be learned from primary care

Given how new full risk is to the nephrology space, we can look to the primary care space as a guidebook for how global risk models in nephrology could play out.

The shift to global risk in primary care began more than a decade ago with the Affordable Care Act’s introduction of upside-only CMS Accountable Care Organizations (ACOs), which aimed to improve patient experience and outcomes while also lowering costs.

We’ve seen growth and positive results of the CMS ACO model, including $1.2 billion in net savings for 2019 across Medicare Shared Savings Program (MSSP)-participating ACOs. That same year, 92% of eligible ACOs received quality improvement reward points.

This program served as a proof point for these types of models, driving innovation in the commercial space and the growth of global risk commercial ventures. Oak Street Health and Agilon Health are just two examples of entities who have been highly successful in these models.

At the provider level, we’ve seen primary care physicians who are still practicing FFS primary care face stagnation in their practice growth. On the other hand, groups who took on more risk have seen significant increases in physician compensation and recruitment, as well as patient growth.

Strive Can Help You Prepare 

Here at Strive, we’re watching closely as the kidney care space embraces whole patient, global risk nephrology, and we’re helping practices make this shift.

In the coming weeks, we’ll share more on the mechanics of global risk and how your practice can prepare for this exciting new opportunity. In the meantime, we’re here to talk. To learn more about global risk in kidney care, email or complete our contact form.

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