Why CMS Will Lead the 2021 Kidney Care Revolution

Chris Riopelle, CEO of Strive Health
After an unprecedented year, kidney care providers, including nephrologists, dialysis facilities, and care extenders are expecting 2021 to follow suit. We will see an overhaul in reimbursement and major industry shifts, partly led by CMS, that will require providers to advance their capabilities in a way that will usher in more widespread innovation. These new models encourage a shift in treatment approach that will deliver earlier interventions and better outcomes. 

The following are likely trends we will see in the new year. 

Value-based Incentives Impact Kidney Care in 2021 

Tying revenue to volume —a fee-for-service reimbursement model — has long been the standard for treating kidney disease. This payment model has led to high hospital utilization, lack of financial accountability, and siloed care management, ultimately leading to increased costs and an uncoordinated patient journey.

In 2017, Medicare spending for chronic kidney disease (CKD) patients totaled $84 billion. That same year, spending for end-stage renal disease (ESRD) patients totaled $35.9 billion. Less than 1% of Medicare beneficiaries have ESRD, yet the condition accounts for more than 7% of overall Medicare spending. The per-person, per-year spend on treating ESRD patients averages nearly $80,000. These unsustainable costs are driving kidney care innovation and prompting several new value-based care models.

To address both the high cost of care and quality of life, the Advancing American Kidney Health executive order was signed in 2019, with a goal to reduce the number of patients progressing to late-stage kidney failure and improving the cost and experience involved with ESRD care.

In September, the Centers for Medicare & Medicaid Services (CMS) released a final rule for the ESRD Treatment Choices (ETC) model, a mandatory approach impacting approximately 30 percent of kidney care providers, beginning January 1st, 2021. This model aims to bring the U.S. up to world benchmarks for both in-home dialysis and transplant rates. 

Reimbursement rates will be adjusted for physicians and dialysis facilities based on home dialysis and transplant rates, first with a positive adjustment to home dialysis claims, then gradually introducing penalties.

CMS Is Paving the Way to Reduce Costs 

The 2021 launch of ETC signals a broader movement by CMS to improve outcomes and reduce costs for kidney disease. In tandem, CMS took key learnings from the Comprehensive End-Stage Renal Disease Care (CEC) model and other specialties’ value-based models to develop the next value-based care iteration: Kidney Care Choices (KCC), which is led by physicians (instead of dialysis facilities) and significantly improves on prior structures. Also launching in 2021, KCC is CMS’ newest value-based kidney care model. ETC is complementary to KCC, meaning participants can be involved in both models at the same time.

KCC offers two voluntary sub-models: The Kidney Care First (KCF), a nephrologist-only model, and the Comprehensive Kidney Care Contracting (CKCC), an ACO-like model. These models will improve outcomes and reduce costs among kidney patients by slowing the progression of CKD to ESRD, increasing home dialysis, increasing transplant rate, and closing gaps in care. 

KCC is centered around the nephrologist, who drives attribution into the model and acts as the quarterback for their patients’ care. The program addresses some of the historic misalignment in kidney care reimbursement by including a greater emphasis on CKD management, encouraging transplant, rewarding investment in interdisciplinary care teams, and leveling payments across dialysis modalities.

Commercial Plans will Closely Follow  

Commercial payors are watching closely. Payors are increasingly adopting value-based care models intended to shift the treatment focus toward proactive and preventative care – looking to incorporate less expensive treatment options and potential remediation through transplants.

Further, there are specific actions that exacerbate cost. For example, “crash” dialysis increases costs per patient by more than $50,000 a year. Creating quality incentive bonuses that correlate with these kinds of high-cost encounters incentivizes providers to focus efforts where efficiencies can be gained.

Payors will likely follow CMS’ lead and adopt similar reimbursement structures to ETC and KCC that place an emphasis on patient management, home dialysis, and transplant. In particular, home dialysis can be a safer way to treat patients who may be at higher risk of complications from viruses, including COVID-19, and must commute to and from dialysis centers several times per week. Traveling to centers this often also can negatively impact quality of life as patients’ schedules are tied to these frequent and lengthy appointments.

As with many value-based approaches, upside-only quality measures are applied at first, encouraging physicians to beat individual or market benchmarks. These programs are expected to focus on ER visit rates, planned dialysis starts and transplantation. 

New Capabilities Drive Success 

Kidney care providers should make plans to adapt to these shifting trends. Success in value-based kidney care requires more preventative care, additional workstreams, and implementing technology that helps clinicians anticipate which patients are at greatest risk for chronic kidney disease (CKD), with guidance on how to optimize the treatment process. 

Kidney care should emphasize early interventions to impact the primary drivers of high costs and poor outcomes. When it comes to value-based care program restructuring, these key principles are instrumental: align providers across the care continuum, become data-and technology-driven, explore new contracting models, and establish partnerships that help you succeed. 

Value-based care models will have a greater impact when physicians work together toward the same quality and cost goals. Aligning efforts across the care continuum by establishing relationships and care protocols with providers such as PCPs, vascular surgeons and hospitalists is a key driver for success. 

Multi-disciplinary teams work together to collectively create and implement a strategy to improve patient care, incorporating IT resources that make the approach dynamic and holistic. 

Leveraging analytics delivers additional insight into a patient’s care journey, the cost and quality of referral partners, and identifies high-risk patients who would benefit from an intervention. Combining data from several sources, including claims, clinical data, live feeds from health exchanges, dialysis machines and demographic information for social determinants of health, algorithms can predict adverse events, including kidney failure during a given time frame, a cardiology event, and even mortality. 

A significant amount of information is available that, when convened and put through machine learning models, can help to get the right care to the right patients at the right time. Data and technology will play a role as population health management is increasingly applied to care for chronic kidney disease patients.

Many providers feel they must build a value-based infrastructure from scratch. Nephrologists are increasingly owning their patients’ full kidney disease journey, but they do not have to own it alone. Know where you deliver your greatest value and form partnerships to supplement those skills. 

Partnerships can complement a practice’s expertise and expand capabilities. The right partner will help on multiple fronts — e.g., supporting care management, creating alignment with other providers, delivering data- and technology-driven resources, and facilitating compelling value-based payor contracts. Seek care management resources, analytic vendors, financial partners, and value-based contracting experts where it makes sense.

Kidney care is about to see transformation at a higher level than has been seen in many years. By changing reimbursement strategies, a significant step is being made in matching incentives to care goals and outcomes that can open the door for further enhancements. These programs are shaping 2021 into a milestone year for kidney care. 

About Chris Riopelle

Chris Riopelle is the Chief Executive Officer for Strive Health and is working to better the lives of under-served patient populations in a way that drives alignment and value for patients, providers, and payors.

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