Three Keys to Improving Collaboration Between Nephrologists and Primary Care Physicians

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August 24, 2021

By Farhad Modarai, DO, Primary Care Physician and Strive Health Senior Vice President of Enterprise Program Innovation

The National Kidney Foundation estimates that 37 million American adults have chronic kidney disease (CKD), with many more at risk. Although people with CKD are often treated by their primary care physician (PCP) for other associated conditions like diabetes, heart disease and high blood pressure, CKD can go unnoticed until symptoms become severe. In some cases, these patients progress to end-stage renal disease (ESRD) and crash into dialysis without ever receiving care from a nephrologist.

For CKD patients to get proper care, Nephrologists and Primary Care Providers must work together.  But collaboration has historically been difficult.  In this article, we outline 3 ways to improve collaboration.

Most CKD Patients Do Not Know They Have CKD

Nephrology care is critical to ensuring the best outcomes for people with CKD. Nephrologists can provide CKD patients with the medication reviews, nutritional modifications and education needed to prepare for disease progression.  

Not only is nephrology care important for clinical outcomes for those with CKD, but it can also lower overall healthcare costs. Nephrologists help patients prepare for dialysis initiation by coordinating vascular access and easing them toward dialysis treatment. This preparation reduces complications and unplanned dialysis starts, which have been shown to be 67% more costly than planned starts due to associated hospitalizations.  

Despite knowing the value of regular nephrology care for patients with CKD, many still go without. Our data shows that over half of stage-4 and stage-5 CKD patients have not received nephrology care within the past 12 months. A key reason: The difficulty in co-management between primary care physicians and nephrologists.  In fact, primary care physicians highlight the following as barriers to collaboration:

  • Lack of timely information exchange
  • Unclear roles and responsibilities in patient care
  • Limited access to nephrologists

We must overcome the barriers preventing connectivity between primary care and nephrology care.  

What’s Keeping Patients from Seeing a Nephrologist?  

CKD patients are best served by a coordinated, multidisciplinary approach to care. They need a PCP and nephrologist working together to achieve the best outcomes. Value-based kidney care models have evolved with this structure in mind. So, what’s preventing CKD patients from progressing to a nephrologist at the optimal point in their disease progression?  

There are several factors at play in preventing timely nephrology care. They include:

  • Acceptance: Patients may not want to accept that they have CKD, which would mean they’d have to acknowledge the potential for organ failure.
  • Adherence: Patients may not follow through on referrals to a nephrologist, or they may wait until too late in their disease progression.  
  • Behavioral health: Patients with under managed or undiagnosed anxiety or depression may be less likely to address their CKD diagnosis.  
  • Social determinants of health: Any social barrier to healthcare can make the management of a chronic condition more challenging.  

Three Ways to Increase Connectivity Between Primary Care and Nephrology

Knowing the right time and way to start engaging a nephrologist in a patient’s care can be challenging. Though some problems may be associated with accurate CKD diagnosing and staging, it’s more likely that PCPs are managing patients’ multiple co-morbidities, many requiring more immediate attention.

Historically, nephrologists haven’t been as focused on earlier stage CKD patients, but this is beginning to shift. Value-based kidney care models, like ESRD Treatment Choices (ETC) and Comprehensive Kidney Care Contracting (CKCC), incentivize nephrologists to do more upstream management of kidney disease patients. This will require better connectivity with PCPs. It will also require the right data and analytics partner to gather meaningful insights.  

Here are three ways nephrologists can ensure successful collaborations:

  1. Help PCPs identify CKD patients who need nephrology care.

Early engagement with a nephrologist can ensure both a delay in CKD progression and provide optimal dialysis and/or transplant planning, when appropriate. Research shows a more favorable morbidity and mortality profile for patients who experience this proactive approach to kidney care.  

Data-driven insights are a vital step toward achieving early intervention. Under various value-based arrangements, it is possible to mine patients’ lab and diagnosis coding data to identify those who need nephrology care. For example, a dataset that includes both International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes could identify patients who have been diagnosed with late-stage CKD but are not under nephrology management.  

  1. Invest in coordination with primary care physicians in your area.

While CKD identification and referral are critical, proper collaboration doesn’t end there.  To ensure optimal patient outcomes, nephrologists must also provide education and develop care protocols that extend beyond initial referral.  

CKD and ESRD are serious conditions but they’re only a portion of the many issues PCPs see among their patients. Compared to a condition like high blood pressure, which affects 46% of the population, just 15% of U.S. adults have CKD.  Further, earlier stages of CKD are merely monitored and do not pose an immediate risk to a person's health.  All of this contributes to fewer standards in place for how a PCP manages their CKD patients, including how to review labs, when to refer to a nephrologist, and which nephrologist to refer to.    

Nephrologists have the opportunity to establish relationships with PCPs and help them identify CKD indicators that signify when a referral may be beneficial.

  1. Align your practice based on quality and cost.

With more than half of PCPs participating in Accountable Care Organizations (ACOs), they’re looking to align with specialists who will help them succeed in total cost of care reduction and hit quality bonus measures.  

Value-based models provide an opportunity for high-quality, lower-cost nephrologists to connect with ACO-participating PCPs.  

Strive Health Supports Nephrologists in Their Transition to Value Based Care

At Strive Health, we offer support for nephrologists and PCPs seeking to partner in the care of people with kidney disease through:   

  • Advanced analytics to identify CKD patients who need a nephrologist

When working with a payor or ACO, Strive Health is able accesses holistic patient data. This includes the ability to identify patients who are coded for CKD, but do not have a nephrologist. This is a priority in stage-4 and stage-5 CKD patients who need to prepare for the transition to ESRD. Once patients are identified, Strive Health can coordinate their nephrology referral.

  • Education programs, EMR workflow integrations, and high-quality nephrology networks

Today’s referrals are often based on anecdotal evidence. Value-based care demands more rigor through data to identify high-quality, low-cost providers. Strive Health can provide the analytics needed to identify the high-quality nephrologist network that a PCP can use in their referral decision-making

  • Resources to help practices position themselves as high-quality, low-cost providers

ACOs are seeking specialist partners with similar cost and quality objectives. Value-based kidney care models present an opportunity for nephrologists to market themselves to PCPs through data. By outperforming benchmarks, practices can demonstrate their value to ACO colleagues.

Want to learn more?  Contact us here and learn more about how to create better coordination between nephrology and primary care, how to overcome barriers in CKD care, and the benefits of partnership.

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