Director of Nephrology shares the ups and downs of participating in Kidney Care First

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In 2019, HHS announced an overhaul of how kidney care is provided and paid for in the United States to better align incentives and outcomes for Medicare beneficiaries.

The Advancing American Kidney Health initiative has three goals: a 25 percent reduction in the incidence of kidney failure by 2030; Switch to home dialysis or transplant for up to 80% of patients with end-stage renal disease (ESKD) by the end of 2025; and doubling the number of kidneys available for transplant by 2030.

At a Saturday session at Kidney Week 2022, the Associate Division Director of Nephrology at the University of Alabama at Birmingham (UAB) described his organization’s participation in Kidney Care First (KCF), one of 4 models available.

Guarav Jain, MD, FASN, described how UAB made their decision to join, the lessons they learned, and the successes and challenges they experienced. Jain is also co-leader of the Alabama Physician Network, the Accountable Care Organization (ACO) within the UAB healthcare system.

Experience and a strong belief in values-based care are necessary, he said. “It just made sense to us,” he said.

The leadership above him was supportive and on board, although he told them upfront that the model would not generate immediate, lavish gains.

The KCF model must include at least 1 nephrologist and 1 nephrology group practice with 50% of the revenue coming from nephrology services. After Performance Year 1, CMS allows other advanced nursing practitioners, such as physician assistants and advanced nursing practitioners, to join.

There must be at least 200 patients with end-stage renal disease (ESRD) and 350 with stage 4 or 5 CKD.

When the KCF was first announced, it was initially aimed at smaller practices, but to broaden the pool of those considering applying, CMS is now allowing multiple practices to combine to aggregate their beneficiary counts.

Monthly payments are capitalized for ESRD and there are quarterly capitalized payments for CKD. To encourage home dialysis, there is a $35 true-up payment per beneficiary.

A key part of the model is that it offers a $15,000 transplant bonus paid over 3 years, “which frankly is the financial backbone of this program.”

One of the challenges, he said, is the model’s quality measures, and the first is called a “gateway” because it’s literally a gateway — failing it automatically means a financial penalty

The Quality Gateway calls for improvement in depression remission metrics and gains in patient activation through 12 months, as measured by a 13-item patient questionnaire called the Patient Activation Measure (PAM). The PAM must be administered at least twice, 6 months apart, to at least 50% of the program beneficiaries.

The short time to show improvement in PAM isn’t the only challenge, he said. It has not been validated in patients with CKD, although it has been in some other chronic diseases, and it requires administrative time.

The utilization measure includes optimal ESKD starts (home dialysis, renal replacement therapy with preemptive transplantation, or in center-based dialysis with an arteriovenous fistula or a peritoneal dialysis catheter) and the total cost of care per capita.

Another major challenge is communicating with CMS which he said has no assigned teams to communicate with via KCF including no dedicated phone number and it can take 2 to 4 weeks for an email to come back, often without an answer. The reply to the e-mail triggers another week-long wait.

“It’s not what we’re used to,” he said to some giggles from the audience. “You know, in science, if you write a long email, you get a long email back.”

When considering whether KCF is a good fit, practices need to ask themselves many questions, such as:

  • What are their experiences with other forms of value-based care (Medicare Advantage, ACOs)?
  • Do you have the workflow?
  • What is your market like?
  • Do you have existing partners?
  • Who bears the financial risk?
  • What is the upfront cost and can they assemble the team needed to execute it?

Jain commended the clinical care coordinator and the rest of the multidisciplinary team, including a pharmacist and a psychologist, for the program’s success, as well as the university’s leadership, which he said agreed to do it because it was the right thing to do for patients.

In a best-case scenario, he said, he expects the program to bring in $1.5 million by year three.

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