By Ben Kuhn, Head of Provider Solutions, Strive Health
Late last year, CMS released details about its new Kidney Care Choices (KCC) program, which includes the nephrologist-only Kidney Care First (KCF) model and the ACO-like Comprehensive Kidney Care Contracting (CKCC) model.
The models have generated a lot of buzz in the kidney care community. The first application round ended in January, and many nephrologists submitted applications for one or both models.
Whether or not you applied, KCC is a valuable tool for showing us where value-based kidney care is heading and how providers must prepare for the future. Each new Medicare model is just one link on the industry’s evolutionary chart – KCC builds on past models such as ESCOs, future Medicare models will build on KCC, commercial payors will follow Medicare’s lead, and the evolution will continue as the industry moves from volume to value.
Here we look at our top three insights from KCC and what they mean for the future of kidney care:
The message is clear: CMS believes nephrologists are best positioned to direct high quality and low-cost care for kidney disease patients, more so than dialysis providers, hospitals, or any other healthcare provider.
How does this play out in KCC? Nephrologists are one of two required participants (the other being a transplant provider), and patients are attributed based on their nephrologist visits. Capitated payments tie reimbursements to quality of care and not sheer number of patient visits, which gives nephrologists greater discretion and flexibility in how they practice. This is quite the deviation from prior Medicare models that centered around dialysis center participation and based patient attribution on dialysis treatments.
This was not done by accident. Results from Medicare ACOs and bundled payment programs show that physician-led organizations significantly outperform those led by other providers, and CMS has suggested that it expects the nephrology-led models to follow this trend.
Nephrology will go the way of primary care – putting nephrologists in the driver’s seat to manage $150B of CKD & ESRD spend in the United States. Value-based kidney care models will rely on nephrologists for participation and attribution, and nephrologists will be front and center in the care model. Further, savvy nephrologists will leverage their newfound leading role in innovative ways when they contract with payors and dialysis providers.
KCC considers the entire patient journey and makes it clear that upstream patient care will become the industry’s priority. The models include built-in quality incentivizes for optimal dialysis starts and for keeping CKD Stage 4-5 patients from progressing to ESRD. Additionally, capitated payments to nephrologists for CKD patients create a new, meaningful financial incentive for nephrologists to manage CKD patient care as intently as ESRD.
The emphasis on upstream patient care is starkly different from prior value-based kidney care models, which only addressed dialysis patients. This shift makes sense. Dialysis is only one touchpoint on the patient journey, and dialysis providers have neither the ability nor the financial incentives to delay progression to ESRD. With nephrologists at the center of the models, kidney disease can be treated across the entire patient journey.
More payment models will incentivize delayed progression to ESRD, preemptive transplant, and planned dialysis starts that prioritize home therapies. Health systems and payors will use their large, integrated upstream footprint of primary care physicians and other specialists to identify CKD patients and refer them to nephrologists sooner. Also expect nephrologists to invest more time and resources to manage CKD care.
KCC makes clear that business-as-usual will not work for most providers. Instead, providers will need new data, technology, and care management capabilities to succeed in value-based care. These could include data algorithms that predict the risk of patients progressing to ESRD, EMR integrations that enable seamless data sharing across multiple providers, and multidisciplinary teams that manage conditions across several specialties (not just kidney disease). Care teams will also need to interact with patients in nontraditional care settings, such as in the home and through telehealth.
Investing in new care capabilities is just one side of the coin. A number of administrative and capital requirements are also introduced in KCC, such as CKCC’s requirement that participants secure a financial guarantee in amount of 7.25% of the total benchmark. For a nephrology group with 10 physicians, this could be upwards of $5 million.
Most nephrologists are excited to bring their practice to the next level with data, technology, and comprehensive patient care. However, the thought of completely reengineering their practice can be unappealing. For example, hiring and managing a team of software engineers likely is not the best use of nephrologists’ time and expertise. This will open the door for purpose-built partners who can support the unique requirements of KCC and other value-based kidney care models.
Kidney care providers will adopt a new suite of specialized capabilities that revolve around data and technology. However, care delivery will still be human – data and technology will empower, not replace, a high-touch and physician-led care model. Providers will either make big investments to build and manage new capabilities or seek trusted partners with aligned interests and financial incentives.
Overall, the world of nephrology is changing, but if KCC is any indication, the changes are moving in the right direction. For providers that can adapt with the new kidney care landscape, the future will be brighter than ever before.
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