Addressing Gaps and Overcoming Barriers in Nephrology Care

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August 24, 2021

By Farhad Modarai, DO, Primary Care Physician and Strive Health Senior Medical Director of Value Based Care

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.

Our data shows that over half of stage-4 and stage-5 CKD patients have not received nephrology care within the past 12 months.  

Nephrology care is critical to ensuring the best outcomes for people with CKD. These specialists 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, 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. We must overcome the barriers preventing better 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 ¾ working together ¾ 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.  

4 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 four things nephrologists can do to ensure success.  

  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. Educate PCPs on when to refer CKD patients  

Although CKD and ESRD are serious conditions, 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.    

Additionally, 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 handles 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, provide education and develop care protocols in support of optimal patient outcomes.  

  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.  

  1. Encourage comprehensive screenings for patients

A referral from a PCP is just the first step toward getting CKD patients the nephrology care they need. Many other barriers prevent patients from taking the next step in their care.

Nephrologists should work with PCPs to better understand and treat social and behavioral health issues that could prevent patients from seeking further kidney treatment.  

Strive Health Can Support You

At Strive Health, we offer support for nephrologists and PCPs seeking to partner in the care of people with CKD. We offer:  

  • Advanced analytics to identify CKD patients who need a nephrologist

When working with a payor or ACO, Strive Health is able to access 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 ¾ through data ¾ 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.

To discuss partnering to address gaps and overcome barriers in CKD care, email info@strivehealth.com or complete our contact form.

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