“Kidney care represents a huge opportunity to deliver on the promise of one of the priorities I’ve laid down as HHS Secretary, getting better value out of American healthcare…We need to shift from a system that pays for sickness and procedures to one that pays for health and outcomes. There is no better example of an area that demands this shift, and the consequences of inaction are higher nowhere else, than in kidney care.”
— Alex Azar, HHS Secretary, in a speech to the National Kidney Foundation, March 4, 2019
Health & Human Services (HHS) Secretary Alex Azar’s interest in improving kidney care is both professional and personal. His father was a dialysis patient who is now thriving after a transplant. It’s clearly important to him that value-based care have an impact on treatment and outcomes in this space.
Secretary Azar and officials at the Center for Medicare & Medicaid Innovation (CMMI) are betting that building an alternative payment program for providers treating renal disease could provide models for other chronic conditions such as diabetes and heart failure. In 2016 end-stage renal disease (ESRD) beneficiaries comprised less than 1 percent of the Medicare population, but accounted for an estimated 7.2 percent of total Medicare fee-for-service spending, or more than $35.4 billion.
CMMI is experimenting with a five-year model that involves a targeted approach to changing the way Medicare pays for ESRD care. In the 37 End-Stage Renal Disease Seamless Care Organizations (ESCOs,) dialysis clinics, nephrologists and other providers have joined together to coordinate care for matched beneficiaries and are accountable for clinical quality measures and financial outcomes.
The biggest player in the five-year ESCO program is Fresenius Medical Care North America (FMCNA), a vertically integrated healthcare company focused on renal care that includes a network of 2,400 dialysis facilities and an insurance company that allows it to participate in new models of value-based care that take full responsibility for the patients it serves. The company began transitioning to value-based care more than five years ago. “We truly believe that the value-based care arrangements we are in provide us with an opportunity to provide better care to patients and improve their experience of care,” said Terry Ketchersid, M.D., a nephrologist who is senior vice president and chief medical officer of the Integrated Care Group of FMCNA.
Speaking at the Population Health Colloquium in Philadelphia in March, Ketchersid, noted that years ago when he delivered great care that avoided a hospital stay for his patient, the financial advantage accrued to the payer. “But in a value-based care program, I get part of the savings and can reinvest some of that money in patient care and buy things I could never buy in a fee-for-service mechanism. When we and our nephrology partners are jointly taking downside financial risk for this patient population, there is nothing more powerful in aligning our interests.”
Ketchersid noted that ESRD patients spend up to 12 hours per week in dialysis clinics. “We have established phenomenal relationships with those patients. Now we are able to leverage that relationship as we make changes in care that are necessary to succeed in a value-based world,” he explained.
ESCO nephrologists can spend time thinking about what is happening to their patients during the time they are not in dialysis. “In a fee-for-service world, we are laser-focused on providing a safe, effective treatment, but we don’t spend a lot of time thinking about what decisions and barriers patients face outside our clinic,” Ketchersid said. In the value-based care world, if a patient is missing dialysis sessions, a social worker can conduct cognitive behavioral therapy to solve housing or nutritional issues and the patient can spend far less time in the emergency department and may not be admitted as often. “Outside of the value-based care environment, we can’t fund the infrastructure to deliver that kind of care,” he noted. “It is one of the valuable opportunities that exists within these programs.”
Today almost 30 percent of the U.S. patients Fresenius dialyzes are involved in a two-sided risk arrangement with either Medicare or a commercial payer. “We couldn’t do that without the insurance expertise that is brought to the table by Fresenius Health Partners,” Ketchersid said, “which was organized by FMCNA to lead its transformational initiatives in designing and delivering value-based care programs.”
Ketchersid described ESCOs as basically Pioneer ACOs for Medicare beneficiaries who require dialysis. He stressed that the ESCO model is far from perfect. “We weren’t really sure about it when we dipped our toe in the water in 2015. We started out working with six of the 13 ESCOs in operation. In 2017 they opened up the application process again, and we took a much bigger bite.” Fresenius is now involved with 24 of the 37 ESCOs in the country, caring for about 85 percent of that patient population. It has 112 nephrology practices as partners in these programs taking two-sided risk.
“Our participation has allowed us to learn a tremendous amount,” Ketchersid said, “and has given us the scale necessary to extend our care coordination infrastructure even more.”
The nephrologists’ experience
Several nephrologists involved in ESCOs joined Ketchersid in describing their interest in participating in ESCOs and their experience so far.
Michael Casey, M.D., a nephrologist with 20-physician North Carolina Nephrology Associates in Raleigh, N.C., said that the ESCO model allows his organization to generate savings through better health, not less care. He used flu shots as an example. “There is nothing in the current fee-for-service model to account for taking 25 minutes to sit down with a patient and allay their fears and help them understand why it is important to get a flu shot, not just for their health but for the health of their children or elderly grandmother who lives with them,” he said. “In our ESCO model, flu shots are one of our quality metrics, so if we didn’t hit a quality metric, we were penalized. But also, every hospitalization we prevent, we share in those savings. That money pays for us to spend extra time with patients. These advanced payment models allow us to be rewarded for those extra touches and time with patients, and allow us to have healthier patients.”
North Carolina Nephrology Associates uses PatientPing to get hospital ADT (admission, discharge, transfer) feeds sent to its care navigation center when a patient has arrived in the emergency department. They send the ED a medication list and the patient’s last treatment run sheet, and if one of the nephrologists is in the hospital, he or she can intervene sooner rather than later, to help direct their care. “By interacting with the ED physicians and going to see the patients, we can help guide their care,” Casey said. “We can help shorten their time in the emergency department and allay utilization of unnecessary tests, and if the patient needs urgent treatment, we are well equipped to handle that and identify those needs and get the patients the care they need more rapidly.”
Cosette Jamieson, M.D., a nephrologist with Metro Renal Associates in Washington, D.C., noted that CMS is interested in providers working on chronic kidney disease (CKD) prevention. “We need to take care of patients before they end up in renal failure. How can we do that? We need to educate patients as to the main causes. As we know, it is mainly diabetes and hypertension, and a big risk factor for those is obesity,” she said. “I have developed a strong emphasis on educating patients on what causes them to develop CKD as they get older. I serve a largely minority population in Washington, D.C., and they are gradually developing chronic kidney disease because they have not been able to manage their weight all their lives, so I spend a lot of time in every visit talking about diet and health. I invite them to cooking classes. I created a large kitchen in a dialysis facility to cook with an audience present and show them how to make food that is healthy for them. One of the holes we have in our population health is to provide ancillary services like good dietary counseling and good psychosocial support to help chronically ill patients manage stress. It is something we have to try to fix.”
Frenesius’ Ketchersid said there are some key areas of opportunity both for improved outcomes and savings in renal care. One involves pre-emptive transplant prior to dialysis. Currently, of the 100,000 people in the United States who reach ESRD each year, less than 3 percent has an opportunity to get a new kidney before going on dialysis. “The potential savings, whether in Medicare or through a commercial insurer, if we can preemptively transplant and avoid dialysis, is huge, not to mention improvements in quality of life,” he added. “Avoiding dialysis ought to be the goal for every patient appropriate for a transplant.”
Thought leaders such as Jefferson College of Population Health’s David Nash, M.D., say that while the value-based train has left the station, it is not moving as quickly as most people think it might have. Ketchersid said one key factor is whether providers have an appetite for risk. “This is risky business. There are people writing checks to payers if they don’t get this right, and people have different levels of appetite for risk. Some large sophisticated nephrology practices would love to take on more; some smaller ones want to take on as little as possible.”
Sidebar: What Large-Scale Diabetes Care Transformation Looks Like
When it comes to population health for complex conditions, addressing clinical variation and clinical inertia can have a big impact in a short timeframe. For Pennsylvania-based Geisinger Health, diabetes is a priority as a high-impact chronic condition. It has more than 42,000 patients diagnosed with Type 2 diabetes and another 117,000 patients with prediabetes. “Every single month we have a minimum of 500 patients newly diagnosed with Type 2 diabetes,” said Jonathan Brady, PharmD, assistant director of ambulatory clinical pharmacy programs at Geisinger. Also, in the Geisinger service area, one out of every three patients who has diabetes also has cardiovascular disease.
Speaking at the Population Health Colloquium in March 2019, Brady described a multi-pronged diabetes care transformation effort under way at the integrated health system. “When you have a tidal wave coming your way, what do you do? In our case, we got organized.”
Geisinger formed a Diabetes Care Transformation Committee, a diverse group of stakeholders from across the diabetes care continuum. One of its first initiatives was to map out best practices around medication therapy and try to eliminate unwarranted variability from provider to provider in how Geisinger is managing the condition. They made changes that involve leveraging a combination of newer GLP-1 receptor agonists and SGLT2 inhibitors therapies, which are now included in American Diabetes Association guidelines. The health system is embedding clinical decision support in the EHR, keeping care teams up to date with virtual grand rounds, and embedding video vignettes in the EHR.
Geisinger has developed several tactics to address clinical inertia about reviewing patient care plans. Any Type 2 diabetes patient who has not had an A1c test in the last year gets a letter instructing them to report to the nearest lab to get retested. They complemented that step by putting A1c testing devices in clinics so as part of the “rooming” process, you don’t get to the exam room to see the doctor until your A1c is updated. “We are putting primary-care physicians and their care teams in position to make the right decisions at the point of care,” Brady said. “If the A1c is greater than 9, something needs to change, whether your PCP thinks it needs to change or not.”
Geisinger also sent auto-generated letters to every patient with an A1c greater than 9 telling them that they have been referred to a multidisciplinary team that will help them make changes to their therapy. Diabetes-focused huddles review PCP schedules each day, and those patients do not leave the clinic until a plan has been put in place for what Geisinger needs to do for each patient to make changes to their therapy, whether that be diet, nutrition or medications. “We capture that at the point of care with a path forward to get them where we need to go,” Brady said.
So far, all of these tactics have been piloted at Geisinger’s Mt. Pocono primary care center. “We are really seeing the fruits of our labor when all these things are moving in the right direction,” Brady said. “In September 2018, we had 31 percent of our patients at Mt. Pocono who were noncompliant with the A1c less than 9 quality goal. In five months, that number dropped to 22 percent. We are seeing how these tactics have reaped benefits, not only in terms of quality metrics and the numbers that we worry about but also in the lives of our patients. We know that as we expand these tactics across the entire clinical enterprise and to all primary care locations, we are going to see these trends continue to move in the right direction.”
