CKD Comprehensive Care Delivery Model American Society of Nephrology February 23, 2018

Comprehensive Care Model Concept Integration across medical settings and disease phases, led by nephrologists serving as principal care providers, will improve care quality and patient outcomes in late-stage chronic kidney disease (CKD) through renal replacement therapy and/or end-of- life care.

Comprehensive CKD Care Model Goals Span late-stage CKD, dialysis, transplant/post-transplant care, palliative care, and hospice/end-of-life care when appropriate Focus on managing and slowing the progression of kidney disease and other complex chronic conditions kidney patients commonly face Emphasize preparation for and management of care transitions by shared decision-making; improve patient satisfaction and patient outcomes; reduce costs

Which providers should participate in a comprehensive CKD care delivery model? Nephrologists/Nephrology care team Flexibility concerning role of/transition from primary care physicians Other providers may include: Dialysis organizations Health systems Transplant centers Hospices Primary care providers (PCPs) Other specialists/physicians Pharmacy/lab/DME services others Post-acute care Home health services Nursing homes

What patient population(s) should be included in a comprehensive CKD care delivery model? Suggest identifying candidates most likely to benefit using the eGFR 30/20/10 approach 30 or below = handoff to nephrologist as principal care provider/enter model at the very latest 20 = nephrologist helps patients consider therapy options for RRT 10 = nephrologist helps patients select RRT option or conservative care Key questions: How best to serve patients with native kidney disease and the pediatric population?

What is the relationship/role of primary care physician? Access to high-quality primary care services is integral Timing of this transition depends on preferences of physicians involved Individual patient needs and conditions, not reflected in an eGFR, should guide such a transition Model should allow flexibility in design to permit adaptation for patient needs and preferences, and local practice patterns and resource allocation

What are the patient care needs that a comprehensive CKD care model should address? Nephrologists as “principal care providers” would: Understand the totality of their patients’ care regardless of provider Provide care coordination – supervising/arranging interactions with other care providers Manage all transitions of care (CKD>dialysis, CKD/dialysis >conservative management, CKD/dialysis>transplant, transplant >dialysis, >end-of-life) Individualize care and help patients achieve health and life goals (including transplantation and employment)

Patient Care Needs continued Nephrology team would provide/arrange and be responsible for variety of services Delivery of patients’ education for all treatment options Development of a patient care plan with patient and family input, including palliative/advanced care planning Medication management reconciliation (including avoiding nephrotoxic drugs) BP control, blood sugar control, bone and mineral/metabolic management, volume management, and cardiovascular risk management Symptoms management Other

Patient Care Needs continued Non-nephrology care needs could include: Dietary counseling General primary care – which could also be provided directly by some models, if they so choose Other specialty care as needed (e.g. cardiology, endocrinology) Palliative care Hospice care Social/financial support services Surgical care (e.g. vascular access placement/issues, transplantation) Transplant evaluation/transplant pre-and post-care

Which patients would be feasible to include in a comprehensive CKD care delivery model? Ideally, “all-payer” model If all-payer not feasible, within Medicare: People ≥ 65 years (Medicare eligible) and have eGFR ≤ 45 People ≤ 65 years with ESRD (with Medicare as primary payer) and have eGFR ≤ 45 Possibly patients from Medicaid if feasible Maintain patient flexibility to opt-in/out and see other providers Key questions remain: How would eligible patients be identified for/attributed to such a model? What will the landscape of model testing look like post-ACA?

Physician Payment Models See attached ASN letter to Seema Verma, CMS Administrator, November 20, 2017 (both model options begin on p. 4, highlighted in yellow).

What metrics might be included? Potential considerations for definition of success: Focus on one or two metrics that are meaningful from a patient perspective (rather than process or clinical/lab value metrics) Input from patients crucial Cost savings metric(s) Reduce admissions/readmissions and ER visits Slow rates of CKD progression Increase optimal starts to dialysis Reduce the disparities that exist in terms of early dialysis starts (how to quantify?)

Additional/Oversight metrics In addition to requiring achievement of one/two patient-centered outcomes metric(s) and cost savings/value metric(s) model may also assess other “oversight” metrics Potential additional metrics discussed include: Patient experience of care Patient functional status Employment of patients Transplantation access/rates Readmission rates Input from patients crucial

Many Questions Remain What kind of geographic scope might be reasonable (use ESCO as base)? What kind of time length (is 5 years to allow enough time to collect outcome data; population event rate should be sufficiently high that we should see “effect”)? Is a model that permits a “range” of entry points (somewhere around 30 eGFR, optional for native kidney disease patients) feasible/conceivable from a financial perspective? Is there a low-end cutoff point? Conceivably a certain portion of the ESRD population is going to be in the most costly end year(s) of their lives, and the model participants may find themselves caring for people who received none of the upstream interventions that help minimize such costs. Is entry for patients with native kidney diseases a voluntary decision between the patient and the nephrologist at any point that they feel best to provide ‘kidney-centric care’? How are patients attributed? Voluntary/involuntary/opt-out process? What is the mechanism to determine eligibility - one eGFR test, two eGFR tests demonstrating at 30? Where do organizations participating in the model obtain the data to identify potential patient populations? How does this model interface with other models (MSSP ACOs, Next Gen ACOs, ESCOs, etc.) How does the model demonstrate savings? Since many patients with CKD would not progress to having ESRD, how do we show savings in that population? Why has no one been able to cogently quantify the savings of pre-emptive transplantation and transplantation vs. dialysis – it seems rather crucial to this model? How would savings be calculated in the face of a “range” of entry points (somewhere between 45 and 30 eGFR)? How is risk structured? Is the model at total-cost-of-care risk model or just a nephrology-related care risk model? Is there upside risk only or both upside risk and downside risk? How can the model be truly nephrologist-led if other “entities” have to put in the capital to invest in the systems to make the transformation feasible and to assume risk? Could the model function as being led by clinicians only? (E.g. all of the health professionals across the spectrum of kidney disease but none of the entities)