Addressing ESRD Complexities with Integrated Care
End stage renal disease (ESRD) represents a population health conundrum. It affects a relatively small part of the U.S. population—only 600,000 individuals. Yet the rate of ESRD diagnosis continues to increase faster than the rate of U.S. population growth. ESRD also disproportionately affects underrepresented minorities. These patients suffer from significant comorbidities, such as hypertension, diabetes and heart disease that are often addressed in primary care settings.
On average, ESRD patients experience 11 days per year in the hospital and consume 19 pills a day. Thus, the complex treatment of these patients comes with significant costs, the majority (more than 90 percent) of which is paid by government insurance. Despite being only 0.2 percent of the U.S. population, ESRD patients account for 7.2 percent total of all Medicare claims costs, totaling $31 billion in 2014.
The ESRD clinical community has been aligned with the concepts of data collection and population health management through various efforts (such as the United States Renal Data System (USRDS), which collects, analyzes and distributes information about ESRD), protocols for managing ESRD-related conditions and monthly capitation for clinicians that includes services related specifically to dialysis care. The idea of extending primary care to ESRD patients during their in-center visits is newer, driven in part by the Centers for Medicare and Medicaid Services’ (CMS) efforts to place 50 percent of all patients under value-based purchasing arrangements by 2018. ESRD patients represent an ideal patient population to benefit from a combination of personalized care and population health management.
Most ESRD patients spend 12 to 15 hours a week in a dialysis clinic. This provides a unique opportunity to routinely engage these patients in addressing their non-dialysis, healthcare needs and helping them better navigate the health system. This can lead to not only better outcomes and quality of life but also improved cost savings for an overburdened healthcare system. For example, a leading provider of ESRD integrated care programs has reported 29 percent fewer days in a hospital, which translates to more time patients can spend living their lives.
An integrated care model centered on the patient in a dialysis center is a cornerstone of several Medicare ESRD value-based programs.
Figure 1. Illustrative Integrated kidney care model
As with other population health programs, risk stratification is critical. The ability to regularly review and adjust patient risk allows care managers (nurses) to target patients at the highest risk of complications. Nurse practitioners can work with patients and their physicians to facilitate access to specialists and services known to deliver high-value care for specific problems when necessary.
Data related to hospitalizations and patient risk are given back to patients’ nephrologists on a regular basis. This allows physicians to adjust their clinical emphasis as needed, improving the ability to prevent complications for patients. Care managers engage patients on a regular schedule, developing appropriate care plans for new problems and tracking progress for ongoing clinical and social concerns in a care management system. The combined efforts of this multidisciplinary team reinforce care delivered in the dialysis center and provide opportunities for additional touch points outside of a facility, enhancing patient engagement.
The Medicare Advantage Chronic Condition Special Needs Program (MA C-SNP) in California exemplifies the value of an integrated care model for ESRD patients. This program operates with monthly Medicare Advantage payments and flexible service area options, enrolling insurance-eligible patients, often individuals who are dually eligible, via a payer. It offers transportation, dental and vision benefits tailored to ESRD patients.
These programs have achieved:
- Decreased hospitalization rates (26 percent reduction versus USRDS national average)
- Decreased readmission rates (31 percent reduction versus USRDS national average)1
- Lowered rates of central venous catheters as primary access for dialysis (70 percent lower versus USRDS national average)
These results clearly exemplify what can be accomplished through an integrated care model for ESRD patients.
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Some of this content has been republished, with permission, from Accountable Care News.
 2016 USRDS Annual Report, 2015. DaVita C-SNPs in Las Vegas, Los Angeles, Orange County, Riverside and San Bernardino.
 ESRD National Coordinating Center (“Fistula First Catheter Last” Dashboard data). 2015 DaVita C-SNPs in Las Vegas, Los Angeles, Orange County, Riverside and San Bernardino.