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The Importance of Payer-Provider Collaboration In Value-Based Kidney Care

Mar 26, 2023

Chronic kidney disease (CKD) is the ninth leading cause of death and the fastest-growing noncommunicable disease in the United States. Over 37 million people have kidney disease, affecting over 1 in 7 American adults. Approximately 1 in every 5 dollars in traditional medicare, or $114 billion per year, is estimated to be spent on patients across the kidney disease spectrum.

Value-based kidney care models have been replacing the traditional ‘fee-for-service’ model that has been previously dominant in the U.S. healthcare system. Value-based care models are designed to address behavior patterns, such as high utilization, lack of accountability, and siloed care management observed in the ‘fee-for-service’ models.

Key Points:

  • Value-based kidney care models work to leverage relationships between payers and providers to coordinate care and manage or prevent kidney disease progression.
  • Payer-provider collaboration in value-based care models drives improved patient outcomes, lowers overall healthcare costs, slows chronic disease progression, and provides financial incentives to providers.

What is Value-Based Care? 

Value-based care is a healthcare delivery model focused on optimizing the relationship/collaboration between the cost of treatment and patient outcomes. This brings value to payers and patients in an efficient way. Value can be measured using evidence-based approaches and is determined by the outcomes that are meaningful to patients and the associated costs incurred that reflect their medical condition, including any associated co-morbidities.

Four specific categories can define patient-relevant outcomes for CKD patients:

  • Burden of care
  • Survival
  • Patient-recorded health and well-being
  • Treatment specific outcomes

The following components have been identified as critical to a value-based healthcare model:

  • Modern IT systems and standards need to be developed and maintained.
  • Payments are made through bundled or capitation models to indicate value.
  • Care providers must offer a full care cycle for the defined medical condition via integrated practice units.
  • Geographic expansion of care further controls costs and improves outcomes.

Why Value-based Care Models in Nephrology?

Value-based kidney care models have been introduced to address the identified shortcomings of the ‘fee-for-service’ model by improving clinical, financial, and patient outcomes. These models focus on collaboration between payers and providers to benefit the patient and the physician/healthcare professional.

Value-based kidney care was officially introduced three years after the Affordable Care Act was implemented in 2012. The Centers for Medicare and Medicaid Services (CMS) introduced the first value-based kidney care model called The Comprehensive ESRD Care (CEC) Model, which began in 2015 and ended in 2021. The CEC model was the first step in encouraging a more holistic model of kidney care. A further improved model called Kidney Care Choices (KCC) was introduced in 2022 by the CMS.

An example of a recent relationship/collaboration between payers and providers is the 21st Century Cures Act, which encourages patients with end-stage renal disease (ESRD) to enroll in Medicare Advantage Plans. These proposed Medicare payment changes aim to drive innovation and increase access to at-home dialysis for patients.

The Advancing American Kidney Health Initiative, launched by HHS, introduced three goals to drive collaboration further:

  • 25% fewer patients developing kidney failure by 2030
  • 80% of new patients with ESRD should receive at-home dialysis by 2025 or receive a kidney transplant
  • To double the number of viable kidneys available for transplant by 2030.

To reduce the development of ESRD in kidney disease patients, CMS, through the innovation center, released five payment models. These models are expected to increase the enrollment of Medicare patients in arrangements that provide novel incentives to prevent and manage kidney disease.

Why Payer-Provider Collaboration is Important

As providers increasingly adopt value-based care models, they must leverage relationships between payers to coordinate care and manage kidney disease progression. Parts of value-based care model frameworks that are impacted by payer-provider collaboration:

  1. Data-sharing

Access to complete data for both payers and providers can improve the quality of care and create administrative efficiencies. When providers share clinical data with payers, the payers can have a complete picture of a patient’s health. This can enable better quality metrics, enhance price transparency, and improve evidence-based care. Electronic Health Records (EHRs) have been vital in improving collaboration in data-sharing between providers and payers.

  1. Transparency 

Payers and providers need to be made aware of each other’s roles with respect to the patient population. For instance, providers with access to patient medical history should share it with payers to maintain a patient-centric focus and enable better care coordination. Providers also need to know how they perform in relation to other providers in the nation or state. This information can be used to measure the true value of care being delivered.

Transparency increases trust between payers and providers with the aim of delivering better financial and clinical outcomes.

  1. Responsibility and Accountability

Accountability is vital in a value-based setting, and collaboration ensures that each member is

held accountable for their actions. This is important as any decisions or actions can directly or indirectly affect the outcomes. Sharing responsibilities and holding stakeholders accountable in their respective roles goes a long way to aligning incentives, reducing conflicts of interest, and reducing fragmentation in the healthcare sector.

This can be achieved by making sure:

  • Incentives are focused and finite.
  • Healthcare organizations can incentivize both team and individual performances.
  • Organizations can use peer-reviewed feedback to ensure effective incentivizing strategies.
  1. Care and cost outcomes 

Providers and payers can meet their individual goals more efficiently by sharing quality measurement expertise and collaborating to improve healthcare delivery. In this relationship, providers need lower utilization rates, more efficient workflow, timely reimbursements, closed care gaps and increased patient satisfaction. At the same time, payers require mitigated risks, minimization of inappropriate system access, and lower costs. Through integrating operations, stakeholders can achieve better patient outcomes and increase savings.

  1. Patient engagement

By payers and providers adopting a mindset of shared-decision making, patients can be engaged more effectively. For instance, payers can improve patient satisfaction by incentivizing physicians to focus on patient-centric care. The success of a value-based care model is directly related to patient engagement (patient buy-in), as these models are centered on patient outcomes and the cost to produce these outcomes.

In Summary

Value-based care is critical to healthcare transformation, especially in chronic diseases such as CKD. This gives payers and providers an excellent opportunity to develop proprietary value-based kidney care models to disrupt the market and put patients back at the center of their care journey.

Panoramic Health

Panoramic health is a physician-led value-based care platform utilized by leading nephrologists across the U.S. Our approach to delivering value in kidney care results in increased quality of life for our patients and an average of $872 PMPM savings on the total cost of care.

For patients at Panoramic Health, we offer the holistic CKD care coordination you deserve. This, in turn, can help you:

  • Slow disease progression
  • Experience a better quality of life
  • Manage the full spectrum of your health

For providers, we offer a transformative approach to the delivery of value-based kidney care by providing physicians with integrative technology, analytics, and workflow management. Other key features of our value-based kidney care model include the following:

  • Differentiated holistic care model with proven clinical outcomes
  • Industry-leading, multichannel patient engagement across all touchpoints.
  • Unparalleled data integration and analytics engine for advanced risk stratification and predictive modeling.
  • Deep provider alignment with scalable delivery models that can integrate into practices as needed.

As a physician-led organization, we are uniquely positioned to understand the needs of both providers and payers.