By Thomas Watson, MD
There have been amazing medical advances in recent years – a non-smoking acquaintance in his 40’s was diagnosed with lung cancer several years ago, and instead of a life expectancy of six months, he is living comfortably taking a pill designed for his cancer, for which he had a genetic predisposition. We’ve seen these breakthroughs in many fields of medicine, but unfortunately, advancements in treatment for patients with kidney disease have lagged behind.
Due to the cost and complexity of care of kidney disease patients, one area of innovation in which kidney disease care is becoming a proving ground is care delivery. Patients with chronic kidney disease are generally medically complex, with higher rates of heart disease, cancer, and even gastrointestinal bleeding than the general population. They have significant care coordination needs focused on preventing worsening of kidney disease, preparation for kidney transplant, and unfortunately preparation for dialysis when appropriate.
All of these facets of care require extensive education. There are many appointments required with various specialists at many different facilities (for which patients require something as simple as transportation). Patients with kidney disease often require extensive and complex medication regimens. Hard-working nephrologists cannot provide all of this support alone, and deficiencies in care lead to worse outcomes for patients, increased hospitalizations, and greater cost to the healthcare system as a whole.
CMS and private insurance companies are acutely aware of these problems. As a result of a combination of the Affordable Care Act of 2010 and the Executive Order Advancing American Kidney Health of 2019, in addition to a change in eligibility for Medicare Advantage plans for patients with End-Stage Kidney Disease (ESKD), we now have an opportunity to partner with both CMS and private insurers to make radical changes to our care delivery models in an effort to increase education and care for patients with kidney disease – and doing so should lower costs.
There are a number of healthcare companies attempting to provide some of these services via care management systems run primarily by nurses and other support staff, often remotely, and rarely in partnership with a patient’s physician.
As we all know, Value-Based care is the popular phrase for this delivery model, but I prefer a less catchy, but more accurate phrase: Physician-driven, patient-centered care. It is physician-driven because nephrologists will be taking responsibility and financial risk for every facet of their patients’ care. It is patient-centered because every medical decision we make in partnership with our patients will be guided only by what is best for those individual patients. I would like to think that all of us as physicians have always made decisions for patients based only on what is best for them – but in a fee-for-service system, we must all recognize that distorted incentives exist that can affect care.
Along with 16 other practices nationwide, our practice has partnered with Evergreen Nephrology to provide physician-driven patient-centered care to our patients.
Over the next few years, we expect to provide these expanded services to a majority of our ESKD and advanced CKD patients. We will be doing home visits, providing mental health support services where needed, addressing transportation limitations, education and patient engagement, food insecurity, early support and education for transplant services, medication review and education, just to name a few facets of care. Using data analytics, we will access all of a patient’s available electronic health information and leverage that predictive modeling to identify and intervene on the highest-risk patients to make their lives better. We will be focused on disease prevention and stabilization to reduce the number of patients who are forced to start dialysis or undergo transplantation. For those who worsen despite our best efforts, we will be helping to coordinate kidney transplantation when possible – hopefully before a patient ever needs dialysis. For those who are forced to start dialysis, we will be focused on Home Dialysis modalities which have equivalent outcomes to standard in-center dialysis, but much better quality of life scores at a lower overall cost.
It is an exciting time in nephrology as a result of these care delivery innovations. Our programs began for a small number of patients on January 1, and we hope to increase those numbers dramatically over the next several years. I feel certain that our efforts will yield happier and healthier lives for our patients, and I can’t wait to see to see the results.
Thomas Watson, MD practices with Nephrology Associates. He is Board-Certified in Nephrology and Internal Medicine by the American Board of Internal Medicine.