DaVita CMO on the Impact of Value-Based Models on Kidney Care
Fortune 500 company DaVita is one of the largest kidney care companies in the United States. It has about $5 billion at risk in value-based contracts and is on a pathway to have about $10 billion at risk for patients with kidney disease. Jeff Giullian, M.D., chief medical officer at DaVita, recently spoke with Healthcare Innovation about some of the things alternative payment models are allowing the company to do to provide more holistic care to patients.
Healthcare Innovation: What are some of the things that you focus on in your role as chief medical officer at DaVita?
Giullian: I get to think about our global clinical strategy every day, which is really exciting because we're at a time in kidney care probably unlike any time we've had since the 1970s. We're in a time of really robust innovation of care delivery, which for me has always been an area of healthcare I've had a lot of interest in. How do we optimize care delivery in a manner that gives our patients the best experience and outcome, but also gives society the best value possible?
I get to think in terms of patients with chronic kidney disease, patients with end-stage kidney disease, patients with transplants. I get to think about how we provide dignity at the end of life across that entire continuum of care for a patient that's living with kidney issues.
HCI: What are some ways that the model can become more patient-centric? Are there more high-touch opportunities, with telehealth or digital health to check in with patients more regularly?
Giullian: You know, there are a lot of tactics, and telehealth is one of those tactics, but as I zoom out, and I think more philosophically, more strategically about what we're trying to do, to me it's all about how we reduce fragmentation in healthcare, and it's one of my biggest frustrations as a physician, one of my biggest frustrations as a physician executive.
What happens when a patient has real complexity in their life, when they've got cardiac issues and they've got kidney issues and they've got peripheral vascular disease? Then it's not just additive, it becomes exponential in terms of the complexity. Hw do we defragment care and then how do we improve the experience for a patient in a way that helps them navigate all of this? We've got teammates who are embedded in physician practices. We've got teammates in Integrated Kidney Care who work directly with our dialysis teammates, and we've now hired teammates to help directly with the transplant process as well, especially for the more vulnerable subset of patients who may be dual eligible for Medicare and Medicaid, or live in an area where navigating a kidney transplant — getting listed and remaining active on that list — is harder.
As you dig deeper into the tactics, it is not only about what touch points are needed, but where are those touch points needed? They are needed at the points of transition for a patient, when a patient moves from having early or moderate chronic kidney disease to having more advanced kidney disease and meeting with a nephrologist, that's a transition point. If that patient then moves to much more advanced chronic kidney disease and needs education about preemptive transplant, education about modalities, education about conservative care, that’s another pivot point where we need to have high touch. If they transition into dialysis, if they end up in the hospital, and they transition back, if they end up at a skilled nursing facility, every single place like that is where we are embedding resources, time, energy, effort, and technology to try to give that high touch and defragment the care.
HCI: Is there a role for their primary care team in that as well?
Giullian: Primary care is a bit of an enigma in patients with advanced chronic kidney disease, especially those on dialysis. I practiced in an area where our primary care physicians were highly engaged with us as the nephrologist in the care of a patient living with ESKD. That's not universal. There are a lot of places where primary care becomes very hands-off when a patient becomes a dialysis patient or a transplant patient. Our focus is to figure out how do we work within either of those scenarios without having to try to boil the ocean and change an entire geography. So in areas where the primary care team is highly engaged, then we have an Integrated Kidney Care team and a team of navigators to make sure that we are continuing to engage primary care. And in areas where primary care is more hands-off, then we need to fill that gap. So that's what we do on the dialysis side. Now we have pretty significant places where we're actually trying to work directly upstream with primary care to identify patients early and intervene early, so, quite frankly, they never need our services later.
HCI: Do you also use predictive analytics tools to help identify people who can benefit from an early intervention?
Giullian: We’ve got really robust predictive analytics across the spectrum — not just predictive analytics of who's going to progress in chronic kidney disease, but of those who are likely to have problems with it, and end up hospitalized. That data is only as good as our ability to engage the patient and activate the team and the patient in such a way that you change the trajectory. Having the predictive analytics alone doesn't help. Just because I know somebody is going to get sick and progress and end up in the hospital, if we don't have the wraparound services in partnership with the patient, in partnership with the primary care physician, in partnership with the nephrologist, then we've added noise to the system. We haven't added value.
HCI: There’s been an emphasis on increasing at-home dialysis. Have you seen significant progress there?
Giullian: This is a really complex situation. I am a huge personal fan of home dialysis, and so when I was in practice, almost 40% of my dialysis patients happened to be home dialysis patients. I think that there are real opportunities for quality of life for patients. Having said that, it's not as simple as just offering more home dialysis. We've done a lot of analysis on why some people choose to dialyze at home, and why some people choose not to dialyze at home. And the real answer here is it's not everybody's preference. Some patients, whether it is because of their background, or their home support or anything else, actually choose in-center dialysis. So we've said, we want to make sure that we're educating everybody and engaging everybody on their options, and that regardless of what option they choose, we're going to support them as well as we can.
HCI: Are there significant differences in cost or in quality between at-home versus in-center dialysis?
Giullian: I would say modest differences, and some of it is a little bit hard to parse out. In general, people who are on home dialysis tend to have fewer hospitalizations, and hence they cost the system less money. But it's not quite clear that it's because they were on home dialysis. Generally, a healthier patient who has support at home, who's more engaged in their care, would choose home dialysis, and that patient, by virtue of who they are, is less likely to be hospitalized. Somebody who might be more medically fragile, more complex, and have other needs is more likely to be on in-center dialysis. So it's a little hard to parse out whether it's the home dialysis itself or the population of patients who dialyze at home, but in general, if you just look at the raw data, slightly lower costs, slightly fewer hospitalizations as well, and slightly higher likelihood of getting a kidney transplant. So when we can engage our patients and give them the tools to be a real advocate for themselves and a real part of their care, we find that that's got meaning for them in a broad way.
HCI: Can we shift to talking about value-based care? I know kidney care, in general, is one of the areas leading in the shift from volume to value. How does DaVita participate in value-based care programs that focus on total cost of care?
Giullian: DaVita has been involved in this for a long, long time, both with commercial insurance and with public insurance. We started very robustly in value-based care back in the mid 2010s in something called End-Stage Renal Disease Seamless Care Organizations or ESCOs. And we were successful there, and took lots of learnings, and that has propelled us to this next phase, which I call version 2.0 of value-based care.
Right now, we have about 80,000 patients in value-based care programs. We have about $5 billion at risk, and we are on a pathway to have about $10 billion at risk for patients with chronic kidney disease, early, late, end-stage renal disease. We are beginning to work with others to determine how we could do this as well for people who are living with a kidney transplant — again, trying to reduce those fragments of care and make sure that we're taking care of patients in the right ways, early, to prevent problems later, to mitigate those problems, and even later to make sure that as they're getting very complex care, like a transplant, like dialysis, like end-of-life care, that it's as seamless as possible. So we're very excited about it.
HCI: Has DaVita participated in other CMMI alternative payment models, like Kidney Care Choices?
Giullian: We are heavily involved in the CKCC [Comprehensive Kidney Care Contracting] model with CMMI. We meet with CMS and CMMI on a regular basis to provide them feedback, and we participate at an industry level as well, to make sure that we're sharing learnings and ensuring that we can make a program as positive for patients and as positive for society as possible.
HCI: Are those programs allowing nephrology practices or care teams to invest more in addressing people's social determinant issues — to make sure they have transportation or healthy food — than they were able to before if they weren't being reimbursed for those things?
Giullian: Yes, absolutely. And there are two reasons for it. One of them is reimbursement. It's not actually that we get reimbursed for it. It's that now, if it helps reduce total cost of care, there's a funding mechanism for that. What's equally important is that the value-based care programs with CMMI provide us with some safe harbors that we didn't have before.
Nephrologists are independent providers. We don’t own their practices, but they are a referral source to us, so for many things, we have to keep an arm's length from them, so that it doesn't look like we're providing something of value to them or to their patients to induce them to come to us. So many times, there were things that we wanted to do that we knew would be great for patients, but there were restrictions through Health and Human Services because we needed to keep that arm's length. Transportation is a great one. We know that if a patient can't make it to dialysis, they are significantly more likely to be hospitalized for any number of reasons. If we can just get them to the dialysis facility, we can oftentimes take care of them in a manner that doesn't require them to go to the emergency room. But in the past, if we provided some form of transportation ourselves to a patient, it was seen as using that for them to come to us for a fee-for-service treatment. Within value-based care, because we're taking a holistic approach and we have got these safe harbors from the government, we can now do things that we think are in the patient's best interest, and ultimately, that allows us to take a more global view of that patient.
HCI: One of the things that people in the value-based care arena say is that it's challenging to deal with all the quality measures they have to meet in commercial and CMS programs, and that those measures are often not very well-aligned. Do you have that experience?
Giullian: I'm not here to to toot our own horn, but because of the longevity of the time that we've been working on this, we can often go in and meet with our counterparts. Oftentimes that's myself or another physician meeting with a physician executive at a payer and talking doc-to-doc about this, and saying, ‘Look, I understand you want these five metrics, but let's peel it back a layer. Why do you want those five metrics, and what is it that you're trying to achieve, and what is it that you're trying to show your stakeholders?’ It often comes down to the same things. Are we doing the things that we know from evidence-based practice improve patient care? Are we meeting the patient's needs in terms of their satisfaction, their experience, their journey? And are there other things that matter to the payer, because it's part of their general value-based care umbrella, and they want to be able to compare an endocrinology value-based care to a renal value-based care to a cardiology value-based care? If we can peel back the reasoning behind that, we can often find a lot of areas where we're aligned.
And sometimes it's frustrating. There are some quality metrics, especially with the government, even though we've been part of the technical advisory committees, where they pick a metric, and we say, ‘I know you picked that metric for the right reasons, but it misses the mark for so many reasons.’ That's frustrating. We've got close ties with with our counterparts at CMMI. We share that with them, and, of course, they're trying to meet the needs of their constituents as well.
HCI: Is there anything else that we haven't talked about that you want to stress?
Giullian: Everybody's excited right now about AI and virtual and telehealth. I always walk into meetings and say, ‘Look, I'm going to be the Luddite. All of that stuff is cool. But let's not forget, the most important thing we do for patients as physicians, as nurses, as nurse practitioners, is we lay hands on our patient and we are with them, side by side, emotionally and physically. Putting a stethoscope on a patient is more than just listening to their heart. It is truly about connecting with their heart. We're just trying to make sure that we're balancing all of the great, exciting technology that's coming down the pike with humanitarian care.
