A recent JAMA Health Forum A study found that the Centers for Medicare & Medicaid Services’ End-Stage Renal Disease (ETC) Treatment Options alternative payment model showed no statistically significant impact on home dialysis use or kidney transplant rates. Innovation in health care We recently discussed the study with Amit Kapoor, MD, chief nephrologist at Strive Health, a value-based care company focused on kidney disease.
Healthcare Innovation: Before we begin talking about CMS’ ETC model and this study, could you describe your background and role at Strive?
Kapoor: I am a board-certified, practicing nephrologist. I started in private practice in 2006, at a small group based in Darby, PA. I was responsible for merging our practice with a larger group in the area, so we became a large nephrology group and my role evolved in the practice to take on more of a management role and I earned my MBA. I then began working closely with DaVita on their value-based care model. This opportunity came along with Strive in 2021 to lead provider relations. We have expanded our footprint to over 700 nephrologists nationwide, working with us at CKCC. [Comprehensive Kidney Care Contracting] and other value-based contracts. I oversee that from a clinical perspective. As the director of nephrology, I work on provider integration, provider engagement, customer success, really supporting our practices to achieve the best outcomes.
HCI: This study in JAMA Health Forum There was no statistically significant difference in the use of home dialysis or kidney transplantation between regions randomly assigned to the ETC model and regions in the control group. Can you tell us whether this is surprising or disappointing, or whether there were aspects of the model design that might explain it?
Kapoor: As a North Star goal, you want to increase transplant rates and home dialysis penetration. I think the premise of the model and the goals of the model were obviously well-intentioned. I would say the model was somewhat successful in a couple of ways. One is that we saw a change in behavior. We saw an overall increase in home penetration rates. We saw everything go up slightly, about 2% across the board. So it’s one of those things where a rising tide lifts all boats. For example, in dialysis units, there’s more pressure to get them out of the chair and into the home setting, or even to get transplants done. So I think that’s the positive.
Also, with this kind of initiative, where we’ve been practicing the same way for decades, you’re not going to see a huge change in two or three years. The dialysis unit is approaching it in a different way. Whereas before they were looking at it, unfortunately, from a financial standpoint. Reimbursements are better if you keep patients in the chair. But it’s the foundation that’s important. We’re talking to our patients earlier about the process. Our patients are understanding the options better.
Although transplant rates have not increased, we are seeing a greater push for transplants. We are seeing an increase in the number of patients who are getting involved and active and want to learn about transplants. So, I think the pipeline is filling up faster and is more robust than it may have been three or four years ago.
HCI: There was a story in Healing who described this study and published a commentary with it by Eugene Lin, MD, MS, a professor at the USC Schaeffer Institute. I hope we can go over some of the points he made and get his reaction. For one, he said that this ETC model was one of the first randomized trials conducted by CMMI and that, on its own, it could provide insight into the effectiveness of financial incentives for nephrologists.
Kapoor: This is the first randomized trial. We can look at the depth of inequity or disparities in health care by looking at this randomized trial. In other words, who was educated and who wasn’t? Did demographic characteristics play a role in getting better outcomes? How we educate patients, how we talk to them, patient preferences, barriers that they face. So I think this trial could provide a lot of pertinent information in terms of where we saw increases and where we didn’t, and what role did financial incentives play in maybe driving some of that behavior or were the incentives sufficient? Or is it too early in the process to come to a definitive conclusion about incentives?
HCI: Dr. Lin mentioned two other things that he said may have had an impact on outcomes during this period: COVID and the opening of Medicare Advantage to patients with end-stage renal disease. He said CMMI may need to determine what impact those things had on the model.
Kapoor: I totally agree. With Medicare Advantage, we’re seeing a 20 to 30 percent churn rate year over year. Some of that, obviously, is patients dying, moving out of the area, but also a large percentage of that is patients switching plans. So this proliferation of MA plans, where we’re getting to 30 to 35 percent MA plans in some markets, is going to have a big impact on patient behavior.
COVID-19 also obviously disrupted our entire healthcare system. For some of our patients, COVID-19 pushed them home from a dialysis center where there are 20 to 30 patients lined up in a chair; doing it at home was safer for the patients. So I think that’s a positive for some. In other ways it was a negative, because you lost that one-on-one training. You lost the ability to have multiple touchpoints to educate patients and support them in their transition, especially at home. And it also obviously put transplants on hold for an extended period of time. So I think COVID-19 definitely impacted our metrics in a lot of ways, and also the way we deliver clinical care.
HCI: Dr. Lin also said that CMS should consider whether future models should have a similar randomized design. Do you have any thoughts on this?
Kapoor: Yes, I do. This goes back to my concerns about the ETC model in terms of health inequity. Some of the randomization is great, but you also have to understand that there are already built-in intrinsic barriers that limit success for some of our populations. In certain demographic areas where the natural rate of penetration in the home is much lower, partly because of the education that is provided to patients, partly because of housing barriers, the financial inability of patients to connect with their providers, prior to dialysis, in terms of understanding and giving them the right amount of education to support them. So while I like randomized trials, I think we need to take into account these built-in barriers that exist in our population.
HCI: The ETC model had a health equity incentive built in, right?
Kapoor: It did, but I don’t think it was enough, because where we’ve seen units that traditionally had very low penetration in home or transplant, they stayed pretty low because of those intrinsic barriers. With things like home-based dialysis support, if you don’t have internet access, how can you communicate with the patient at home via telemedicine? So there are a number of things that we don’t take into account as providers that have a huge impact, from a patient perspective.
HCI: Are there aspects of clinical workflow or the way financial incentives are aligned that have hindered growth in transplant rates?
Kapoor: To me, the biggest barrier in transplant is just the whole process of getting a patient from referral to a transplant center and then the next steps, right? You do the initial evaluation, and it’s a pretty lengthy process to get activated on a list in terms of the preoperative testing and labs that are needed, and all the different specialists that are required to activate a patient. So that’s a pretty laborious process for a patient, and the communication isn’t there yet. We don’t have that EMR integration yet, or that connection of systems, so the nephrologist, the primary care physician, or the dialysis units are aware of what’s going on. Oftentimes what happens is patients miss appointments, they miss things, and that puts the patient back to square one. So I think there’s still an isolated component to the whole transplant process, other than the financial incentives.
HCI: Expanding a bit in terms of CMMI, should you consider making more of your alternative payment models mandatory?
Kapoor: That’s a good question. I think we’re going to get to a point where it will become mandatory. About 13.5% of Medicare patients are diagnosed with chronic kidney disease, and many more likely have it and are undiagnosed. We’re going to see those numbers go up for end-stage renal disease. There, 1% of the population is driving about 8% of the cost. So I definitely think CMS is getting to a point where it will become mandatory.
Today, maybe 20 to 25 percent of a practice’s operation is based on a value-based care model. I think in the next five or six years, it will probably be more like 60 percent in a value-based care model, where they’re paid through incentives.
But CMS needs to protect practices. What hurt us the most last year was the retrospective trend adjustment, where CMS basically said that because of the use of services during COVID, the benchmarks were much lower than we had previously anticipated. So even though we thought a benchmark was x, we’re actually lowering it by $10,000, which dramatically affected the potential for shared savings and also shared loss. I think CMS needs to make sure that there aren’t these last-minute changes. If there are, there need to be safeguards in place to protect practices, because we operate on tighter financial margins, so we don’t have the ability to adapt to these huge changes.
I think practices will be required to participate, but what we might see is some variation in terms of risk sharing and shared savings. When you change a model and say it’s mandatory, but there will be risk sharing as well as shared savings, with safeguards, I think you’re forcing not only practice leaders, but physicians to participate. What we’ve seen historically is that leaders participate, but the average physician still doesn’t understand it. Now, when you go to a physician and say, “Hey, not only can you make $20,000 more a year, but you could lose $20,000 to $30,000,” that changes the mindset and creates more buy-in.
This is where Strive comes in, because if it becomes mandatory and this is how you’re going to be assessed, now there’s real financial risk at stake and you need a partner that has all the tools to help you succeed.
