Shifting from End-stage to Holistic Care in Chronic Kidney Disease Management

New care and reimbursement models reduce costs and improve care quality for people with chronic kidney disease

In the 1970s, Medicare expanded to cover people with end-stage kidney disease (ESKD) requiring dialysis, regardless of age or preexisting coverage. This expansion represented a significant change in how people with chronic kidney disease (CKD) managed and paid for their care. Until recently, however, kidney disease care models and reimbursement mechanisms remained essentially unchanged. That has all flipped in the last two years.

“There’s a lot more to kidney disease care than end-stage care, and that’s been overlooked in models,” says Jackson Brasher, Vice President of Strategy and Development with Strive Health. “Looking upstream for ways to incentivize prevention before someone reaches ESKD could change how we manage CKD.”

Recent trends in value-based and whole-person care — which focus on quality over quantity — offer new opportunities, financial incentives and challenges for organizations looking to improve the quality and cost of care. Brasher discussed these trends, opportunities and challenges in a recent podcast with the Darwin Research Group.

New Medicare policies and programs incentivize kidney-centric care

In the past, the Centers for Medicare and Medicaid Services (CMS) have attempted to change kidney care by creating kidney-specific accountable care programs. Those early attempts, however, were too focused on dialysis centers and nephrologists working to improve the quality of care for people with ESKD. As such, this model did not lead to significant savings, since it largely targeted patients whose kidneys had already failed. Throughout history, most financial incentives for dialysis centers have oriented around fee-for-service economics, which do not incentivize them to shift their focus upstream toward general kidney disease prevention or delaying progression.

Recent CMS policy changes are moving patients with CKD and ESKD into more managed nephrology-centric, value-based care ecosystems. In 2022 CMS launched the new value-based payment model: the Kidney Care Choices (KCC) model, which is the first nephrology-centric, value-based payment model to include late-stage CKD patients. The KCC payment models, including Comprehensive Kidney Care Contracting (CKCC) and Kidney Care First (KCF), position nephrologists as leaders of their patients’ kidney care.

In addition, commercial payors with Medicare Advantage (MA) plans are also assuming significantly more financial risk for this patient population. This comes as a result of the 21st Century Cures Act, which allowed patients with ESKD to choose MA plans (vs. traditional Medicare) for the first time ever in 2021. Together, these models create a foundation for payors and providers to take on financial risk for kidney care.

“So now, two things are happening simultaneously,” says Brasher. “On one hand, commercial payors are on the hook for Medicare Advantage products that they’ve never had to manage before. On the other, nephrologists are now participating in new value-based care models. They had not been before because, historically, nephrology practices have been independent from health system organizations and integrated delivery networks (IDNs). So, everyone participating in healthcare right now is shifting around the strategy table.”

Building preventive models for kidney care creates opportunities but poses challenges

With more significant financial incentives for payors and providers to shift toward prevention, health systems and physicians now face a difficult challenge: How do they design and implement care models centered around prevention?

The key, says Brasher, is building a model from a patient perspective. Specifically, Brasher highlights three critical components of a preventive, whole-person care model:

1. Preventive care through a renal lens
Currently, more than 50% of people have their first interaction with kidney disease through a kidney crash event, which means someone is in ESKD. Preventive care through a renal lens helps providers care for people in earlier stages of CKD to prevent or prolong ESKD.

“You can’t just treat kidney disease in a vacuum,” says Brasher. “You’re always solving for patient comorbidities, such as diabetes or hypertension, through the lens of how those conditions affect a person’s CKD progression. Comorbidities have implications for their diet, the kinds of medications they can take, and so on.”

2. High-touch care
“While patients may see a primary care provider and a nephrologist several times a year, there’s still a lot of days, weeks and moments between these visits where patients need to solve things, such as behavioral and nutritional issues,” Brasher says. A high-touch care approach focuses on reaching out to patients proactively to help them solve these issues. That means targeted, data-driven prioritization to enable meeting patients where they are when they need support.

3. Risk and value-based care
A move toward value-based care often corresponds with a shift in financial risk for this patient population to incentivize more preventive actions that are also clinically better for the patient. The new CMS models and MA options incentivize providers to take on more of that risk. Transitioning to these models, however, requires new structures for delivering patient care.

“As an organization, transitioning to a value-based model means putting in place structures that allow you to impact CKD care and take responsibility for that impact,” says Brasher. “As new value-based reimbursement models emerge that balance taking on upside-downside risk on CKD patients, healthcare organizations need to build structures that allow nephrologists to keep doing what they’re doing. Groups like Strive can then step in to provide a care model that will optimize and support this care.” And importantly, ensure coordination across primary care and the rest of the provider network.

Creating better kidney care: A final thought

“People with ESKD account for 7% of all Medicare spending, despite representing only 1% of the Medicare population. That’s a lot of healthcare usage. If better managed, new models lead to better patient care,” says Brasher. “Despite the challenges ahead, these new models represent meaningful changes to how kidney disease is managed, which can ultimately lead to reduced costs.”

Assuming financial risk for patient care can create challenges. Strive can support organizations transitioning toward value-based and whole-person care by supplementing existing value-based care efforts.

“We are extenders,” says Brasher. “We want primary care providers, nephrologists and the existing care network to be the decision-makers. Strive can help fill in the gaps in care.”

Strive Health partners with nephrologists, health systems, payors and medical groups to create integrated solutions and deliver high-touch care support, making value-based kidney care a reality.