Understanding Chronic Kidney Disease Coverage, VBC Opportunities

November 22, 2023 - Efforts to improve chronic kidney disease coverage have evolved over the last several decades, but the disease remains costly and prevalent.

Around 15 percent of the adult population in the US has chronic kidney disease (CKD), according to the National Kidney Foundation (NKF). The condition is one of two that, in its final stages, can make individuals eligible for Medicare regardless of age due in part to the history of poor outcomes in this patient population.

Years after an end-stage renal disease (ESRD) diagnosis made patients eligible for Medicare coverage, CKD has become a major testing ground for value-based care innovation.

“Many early value-based programs were specifically designed for patients with end-stage renal disease (ESRD) and targeted towards dialysis facilities, including the ESRD Prospective Payment System (PPS), ESRD Quality Incentive Program (QIP), and ESRD Seamless Care Organizations (ESCOs),” an article published in the National Institute on Health’s National Library of Medicine explained.

CKD affects around 35.5 million adults in the US. However, 90 percent of US adults who have the disease are unaware of their condition, NKF noted. Lack of awareness and high treatment costs can drive higher healthcare spending in this population.

By understanding the costs associated with CKD and current value-based care models that policymakers and payers have applied to this condition, payers can better serve their members who have or are at risk of having CKD while reducing costs.

CKD treatment, procedures

CKD treatment depends on the stage of the disease. In the early stages, diet, medications, and exercise can prevent the condition from progressing, the NKF website explains.

Later stages require more invasive procedures. After kidney failure, patients may need a kidney transplant. The process requires a willing donor and antirejection medications along with other prescriptions.

However, the waitlist for a transplant is long. It can take three to five years to get off the waitlist. Approximately 12 patients die every day waiting for a kidney transplant, according to the National Kidney Foundation. While waiting for their new organ, patients will have to undergo dialysis to stay alive, a procedure that cleanses the patient’s bloodstream of excess fluids and waste.

The two types of dialysis differ in their frequency and process. Hemodialysis occurs a couple of times per week and involves taking the blood out of the body, cleaning it, and returning it to the body. Peritoneal dialysis cleanses the blood while it is in the body. Hemodialysis must be done at home or in a dialysis center, whereas peritoneal dialysis can occur practically anywhere.

Complications can disrupt and increase the costs of typical treatment patterns. Gout, anemia, and high phosphorus are common among CKD patients.

The cost of CKD

CKD accounted for nearly a quarter of fee-for-service Medicare spending in 2020 ($85.4 billion). Hospitalization, dialysis, transplants, comorbidities, and other factors can influence the cost of care.

One study analyzed costs based on the UACR and eGFR categories. UACR and eGFR are two metrics that assess albumin in urine and kidney function, respectively, to estimate patients’ risk for chronic kidney disease. UACR’s categories are A1 through A3, with A3 representing the highest risk of kidney disease, and eGFR can be mapped onto the five stages of kidney disease, starting at G2, continuing to G3a and G3b, and then G4 and G5.

In the early stages, costs hovered around $26,889 for A1 patients and $28,064 and $28,6267 respectively for G2 and G3a patients. In the final stages, the price of care crested $42,000 in both metrics. Adverse events and longer hospital stays drove the costs higher between each phase of the disease.

CKD expenditures may vary based on insurance type. Employer-sponsored health plans pay significantly more for CKD care than Medicare. The mean cost per patient per year for employer-sponsored health plans was $37,843, while Medicare paid $22,660. The increase in cost between each stage of disease progression was higher for the private plan than for the public payer plan.

Chronic disease management costs for CKD may depend on a member’s comorbidities as well. Aside from age, the risk factors for CKD include diabetes, heart disease, and high blood pressure. Managing these co-occurring conditions could cost extra.

Some members also experience adverse events. For members who experienced myocardial infarction, their condition cost $21,016 over the month of the adverse event and the three months following the event. Individuals who had heart failure or a stroke paid over $31,000 and $21,000, respectively, over the course of four months.

Value-based care strategies in CKD

Various government programs and institutions have implemented value-based care models for individuals with CKD or end-stage renal disease (ESRD), according to an Advances in Kidney Disease and Health article.

For example, accountable care organizations (ACOs), which band together and contract with CMS to affect health outcomes in a certain population, have tackled unnecessary hospitalizations and high expenditures among CKD patients. The care coordination capabilities of this model have effectively lowered costs and utilization.

CMS programs like the Hospital Value-Based Purchasing (VBP) Program, Merit-Based Incentive Program (MIPS), and Hospital Readmissions Reductions Program (HRRP) have impacted how the healthcare system reimburses for CKD chronic disease management, and some can improve costs, the authors added. However, some programs’ results are less than sterling, and certain facets demand reform.

For example, HRRP has received widespread approval from hospital leaders for its ability to reduce readmissions, but some studies have found that these reductions may coincide with higher mortality rates. MIPS measures certain scores related to CKD, but nearly perfect clinician scores have called into question the program’s ability to differentiate high- and low-quality CKD care.

Payment strategies like bundled payments and episodes of care can have an influence as well. However the results may be mixed. One bundled payment program successfully decreased Medicare fee-for-service (FFS) payments but did not see significant net savings.

The authors noted that there have also been more targeted efforts to introduce value-based care into kidney disease management. For example, the ESRD Quality Incentive Program (QIP) assesses dialysis centers for quality of care. However, the impact of this program is unclear.

ESRD Seamless Care Organizations (ESCOs) imposed shared loss and savings models along with quality measures on participating dialysis centers. Evaluations of this program revealed reductions in hospitalization and catheter use.

The 2019 Advancing American Kidney Health (AAKH) Executive Order created two payment models for CKD, the ESRD Treatment Choices (ETC) model and the Kidney Care Choices (KCC) model. These models were the first to center nephrologists in value-based care for CKD.

ETC is a pay-for-performance program. KCC has two versions in which nephrologists can participate. One part leverages quarterly capitated payments along with transplant bonus payments and quality-based payments. The other part uses a shared losses/savings model.

“Given the intensified federal attention on kidney disease, now is the time for nephrologists, kidney organizations, patients, payers, and policymakers to partner on meaningful value-based care reforms,” the authors of the Advances in Kidney Disease and Health article concluded.

“AAKH-based payment models, MA plan expansion to ESRD patients, and MVP development are positive first steps, but greater iteration will be needed to achieve the most positive outcomes for patients and curtail healthcare expenditures.”

Commercial payers have also taken steps to improve value-based care in CKD care, especially now that Medicare Advantage plans can receive ESRD patients. The influx of ESRD patients into Medicare Advantage plans has been a key motivator in expanding value-based care coverage for this population.

Intervention strategies

Payers may try to identify members who are at risk for developing CKD or who are in the early stages of the disease. As NKF noted, most Americans (90 percent) with CKD do not realize they have it. Catching any disease early is the best way to prevent higher costs later in the patient’s healthcare journey.

This was one of the goals of Providence Health Plan’s partnership with Interwell Health, announced in 2023. While the partners will serve members with late-stage CKD, they will focus on catching the disease earlier, a strategy Interwell Health used to reduce unnecessary hospitalizations by 34 percent in the past. Members also have access to a multidisciplinary team.

Additionally, payers seeking to improve care for CKD members may focus on bettering dialysis costs and outcomes. Some experts have proposed limiting the price of dialysis and have warned against steering members from Medicare to private coverage, as employer-sponsored health plans shoulder heavier costs for dialysis treatment.

Payers also can take steps to reform health equity in CKD care. Research indicates that promoting community-based care could improve health equity for members with this disease. Specifically, sharing genetic data with patients in a community-based care setting increased awareness of CKD risk among underserved populations.

Streamlining prior authorizations could improve member experience and member outcomes.

The need for faster prior authorization processes applies to conditions beyond CKD. Still, the delays associated with poor efficiency in prior authorization can have dire consequences for members with this specific disease. A study on chronic kidney disease associated with type 2 diabetes mellitus named prior authorization as a key systemic barrier affecting medication access.

Member education is essential to improving CKD care. NKF offers tools that members can use to exercise more control over their condition, including Kidney Pathways and the organization’s 8-week course, "Take Charge of Your Kidney Health.” There is also a screening tool explainer on the website.

Many payers also emphasize strong care coordination in their efforts to improve chronic disease management for CKD. For example, Humana’s program assigns members a care manager to help coordinate care.

As payers seek to reduce costs among members with complex conditions, understanding the costs and value-based care opportunities of CKD could contribute to lower spending.