Dr. Daniel Weiner examines the benefits and challenges of value-based payment models for chronic kidney disease


There are several gaps in the current value-based payment models available for chronic kidney disease (CKD) management, but some incentives, such as the kidney transplant premium, show the potential benefits of a payment approach. to the next that can impact other areas of health care, said Daniel E. Weiner, MD, MS, board-certified nephrologist and senior navigator at Tufts Clinical and Translational Science Institute.

Weiner spoke during a session at the American Society of Nephrology (ASN) Kidney Week 2022 Meeting entitled, “Pushing the Right Buttons for Better Kidney Disease Management: Value-Based Models.”


Can you talk about the benefits and challenges of the value-based payment models available for IRC that you will discuss during your session at Kidney Week 2022?

I think I’ll mention the shortcomings first. [For] value-based payment models, most of those that exist are all based on Medicare’s fee-for-service (FFS), which until recently, [covered] the majority of patients on dialysis, the vast majority of patients on dialysis—that’s no longer the case.

You have this huge movement to Medicare Advantage and now it’s a minority of dialysis patients who are Medicare FFS. So the models, I think they were very well intentioned, only affect a very small proportion of the population. And so I don’t know how successful they will be, because the vast majority of people won’t be Medicare FFS in 1, 2, 5, 8 years. So you are missing an opportunity here to change things.

I think the other big factor with this is that when people do Medicare Advantage or other payers, they bounce from one payer to another. Thus, an individual payer does not have the same motivations to prevent people from progressing. If you have good indicators in place, they can be incentivized to do this, but if it’s very expensive to prevent something that might be someone else’s problem later from a payer’s perspective, you have some misalignment there. And we know that people switch payers exceptionally frequently. So it’s a really difficult thing.

That said, the patterns are actually quite interesting and you can split them into 2 sets. There is the End-Stage Renal Disease (ESRD) Treatment Choice (ETC) model, which is a mandatory model, and there are the Kidney Care Choice (KCC) models, which are voluntary models. CTE only applies to patients on dialysis and I think it may ultimately be limited in what it accomplishes. It pretty much uses a brute force approach to push more people onto the transplant waiting list and onto home dialysis.

These are good things, but it’s a pretty brute force model with pretty heavy risk and pretty heavy downsides for nephrologists and dialysis units. Above all, it does not enlarge the silos either – it is enclosed in the dialysis silo, in a certain sense, it strengthens it.

The much more interesting models are those of the KCC program and they are voluntary models. I think the most exciting thing there, particularly philosophically, is something called the kidney transplant bonus. It is therefore a bonus of up to $15,000 which is paid over 3 years if a beneficiary who participates in one of these programs undergoes a kidney transplant.

Interestingly, a kidney transplant recipient will often not be seen by the nephrologist in the model. So that’s really a key to success, making sure that patients are informed, that they’re in the best shape possible to get the transplant, that you’re promoting that transplant process.

It will still count even if it’s a pre-emptive transplant, and it’s a way around the fact that systems of care are going to change, but what you do 3 years earlier can still have huge impacts on the road. And I just thought that was incredibly smart and really motivating in the right way. This is an incentive to invest earlier for a huge gain for patients later. And I haven’t seen that too much in other models where it takes that kind of long approach.

I think it’s relevant elsewhere in the health care system, and I’m not smart enough to figure out how to design this, but if you can develop systems where people pay it forward they switch health insurers or changing providers, and so on, but where care that is provided now will have a beneficial impact on a patient and their family years from now, there is some reward for care provided now. I think if we could design a system like that, that would be huge.

It will take a lot because you are overcoming this fragmented American healthcare system. And people in Canada or elsewhere laugh at us when we talk about these things, because it’s like, well, of course, single payer, we can pay forward. It’s not going to happen in the United States, but if we can find a way to cross that different kind of silo and really encourage the right thing now, when it has a 5-year advantage or a 10-year advantage, that would be a huge innovation, and we’re not there yet.


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