I belong to a group of Chief Medical Officers that meets quarterly to discuss current and future challenges in the healthcare system.  The CMOs represent a wide variety of healthcare organizations, including integrated care systems, pharmaceutical companies, insurers, laboratory and pharmacy providers, and multispecialty physician groups.  I am the sole CMO from a chronic disease provider organization.  We recently met with Mike Leavitt, the former governor of Utah and former secretary of Health and Human Services under George W. Bush.  Mr. Leavitt is currently founder and chair of Leavitt Partners, a consulting firm in healthcare.  This was an intimate session with 10 or so CMOs participating with Governor Leavitt, and I was impressed with his view of the future of healthcare over the next four to six years.  The key points include the following — I have added what I see as the direct relevance for the future of kidney care:

1. Shift from compassion to dispassion. With the global economic crisis, including the serious economic downturn in the United States, dispassion (NOT the opposite of compassion) is becoming the decision driver rather than compassion.  Countries realize they cannot do everything for everyone.  In the United States this means that “good enough” will become an important part of the construct of healthcare delivery.
   Relevance for kidney care: We need to start being far more proactive in determining who is really going to benefit from dialysis, as well as when to work with families and patients when ongoing dialysis is just not improving a patient’s quality of life.  End-of-life care/palliative care need to be addressed much more openly and aggressively.
2. Networks. One only needs to look at the airline industry to see that networks have become an essential way of doing business in order to survive.  The future of healthcare will depend on robust networks, and in order to play providers have to form them or be part of them.
   Relevance for kidney care: It is likely that continued consolidation in the dialysis industry will occur, and will be required in the new healthcare world.  Survival as individual facilities or physicians will be increasingly difficult.  Should ACOs or other models of integrated care management continue to expand, nephrologists need to find their place in these networked organizations.
3. Buses, taxis and limos. Think of the city manager charged by the citizens to develop a public transportation system.  He decides taxis would be convenient and cost-efficient.  Over a few years, people in other cities hear about this, like it and move to the “taxi” city.  Soon the system is overloaded, more taxis are needed, taxes rise, and people start moving out or the wealthy stay but hire limos to continue to provide convenience.  The city decides, in order to provide transportation, it must switch to buses.  People complain, but the bus gets them where they are going.  In healthcare we are moving to getting from A to B, regardless of convenience — regionalized services, waiting periods and the like will all be necessary in a world of growing demand and increasingly limited resources, unless consumers pay for the level of convenience they want.  The question is can quality NOT be tiered despite tiering of convenience?
   Relevance to kidney care: Nephrologists are the gatekeepers of quality.  This responsibility cannot be delegated to other entities.  This will be increasingly important as more and more care will be “good enough”.  Nephrologists must be part of such discussions and always continue to advocate for what is best for their patients.
4. Three competitive entities. These are large multi-specialty groups, insurers and hospitals.  None of the three has all of the ingredients, and the real question is who is the “general contractor” for the healthcare delivery in a city or region.  General consensus is that of the three, hospitals have the least clue and have been the least innovative in preparing for the new world.
   Relevance to kidney care: Be wary of aggressive moves by hospitals to acquire practices or tie nephrologists into exclusive agreements.  This sector of the industry seems the most “dinosaur-like,” and maintaining agility in nephrology practice is one of the key ingredients to continued success.
5. Cinderella and the ball. Speed and timing will mean everything in determining winners and losers.  The smart players will be inching toward the door of the ballroom at about 11:50 p.m. so that they beat the stampede to the midnight pumpkins and get trampled in the process.  The movement toward integration of the care systems is moving more rapidly than most people think.
   Relevance to kidney care: It is essential that nephrologists stay educated on the moving playing field of healthcare in general and nephrology in particular.  Know who the leading players are, and be prepared to initiate a partnership/collaboration when the stars align — in this case, early in is likely to be the best approach, if you have the right partner.
6. Kodak moment. Kodak had the dilemma of basing its brand on film, even as the world of digital photography was developing.  It was promoting the latter while still basing its core business on the former.  The winners in the new care paradigm are those who have figured out what disruptive technology is coming and how to prepare for it.
   Relevance to kidney care: Nephrologists must be proactive in testing new approaches to delivering kidney care.  Such things as every-other-day dialysis, more frequent dialysis in-center and wearable devices are all talked about, and if they provide significant incremental clinical advantages, patients should have access to these.  The barriers of inadequate reimbursement, however, are real but starting slow, and demonstrating overall value (quality/cost) can push the curve substantially.
7. Leaven in the loaf. It is clear that the first target for realigning healthcare will occur at the state level with intense pressure on Medicaid programs to constrain costs for states that are in the midst of massive budget deficits.  This could be fertile ground for experimenting.  Insurance exchanges are likely to grow much more rapidly than initially thought, with employers moving employees into these systems to control costs and shift costs to the employee.
   Relevance to kidney care: Erosion of Medicaid programs will significantly wear down CKD and ESRD patient care.  Nephrologists must be proactive in their individual states to ensure that this vulnerable population is protected.  Similarly, insurance exchanges may significantly decrease fees paid to providers, threatening access of patients to care and the ability of nephrologists and dialysis providers to serve these patients.  An urgent threat is the omission of Medicare Secondary Payer (MSP) requirements for these exchanges, essentially resulting in patients with employer-based insurance being moved to Medicare immediately if they have ESRD rather than waiting the current 30 months.  As recently articulated by RPA/ASN/ASPN, “Patients with End Stage Renal Disease (ESRD) are among the most vulnerable of all Medicare patient populations. It is important to account for the needs of these patients by maintaining funding for ESRD care at current levels. The Medicare ESRD program was recently transitioned to a bundled payment system; the transition included an across-the-board payment reduction. Subjecting the program to further cuts would jeopardize patient access to readily available, high quality dialysis care. We urge you to consider applying the Medicare Secondary Payer (MSP) provision to the recently enacted health exchanges. This proposal not only will maintain current funding levels for ESRD care, but will also potentially achieve billions of dollars of savings for the Medicare program. ASN, ASPN, and RPA urge you to protect ESRD care by keeping dialysis reimbursements whole, and instead consider innovative solutions such as application of the MSP provisions to health exchanges.”*

As the hockey great Wayne Gretzky said, “You miss 100% of the shots you don’t take”.

This approach, and the urgency we and our patients face, is described in an African proverb:  “If you want to go quickly, go alone, if you want to go far, go together.” We have to go far, quickly, and that means we have to quickly find a way to change the world’s consciousness about exactly what we are facing and how we have to work to solve it.

Nephrologists need to look into the future, identify partners whose vision they share, and then together shape the opportunities for delivering even better care and better outcomes despite shrinking resources.

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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*ASN, RSPN, RPA letter to Congress, October 13, 2011.

The New York Times published an article recently about the increasing trend of nurses getting advanced degrees. “[In 2010] 153 nursing schools gave doctor of nursing practice degrees to 7,037 nurses, compared with four schools that gave the degrees to 170 nurses in 2004, when the association of nursing schools voted to embrace the new degree. In 2008, there were 375,794 nurses with master’s degrees and 28,369 with doctorates.”(1)   The concerns expressed by a variety of groups in organized medicine was over the use of the title “doctor” for the nurses who had earned a PhD, with possible confusion of patients over who was a “real” doctor. Clearly this is a smokescreen and the real concern is over control and concern over the slow “intrusion” of nurses into medical practice. This concern is curious since it is clear that there continues to be a significant workforce deficit in primary care and in medical subspecialties such as nephrology.

Recent data from the Renal Physicians Association confirms what all practicing nephrologists already know: The patient population with ESRD and CKD is growing and is increasingly medically complex; the ability to recruit new nephrologists into practices is decreasing, with stagnant training programs and large numbers of IMGs not remaining in practice in the U.S. following training; there is increasing demand on time for administrative activities, including fulfilling the requirements of the Conditions for Coverage to carry out Medical Director activities appropriately; continued pressure from hospitals and other organized care systems to become salaried physicians; and constant downward pressure on reimbursement for physician services. All in all, working harder for less. It is time we applied the age-old adage, work smarter, not harder, and embraced ways of doing this, like working in teams and expanding the use of our advanced nurse colleagues.

There is no area in medicine where the interdisciplinary team (IDT) is as critical to optimizing clinical outcomes as it is in ESRD. Most people, however, narrowly define the IDT as the physician and various teammates in the facility (nurse, technician, dietitian and social worker). This narrow paradigm is critical for driving outcomes, as we showed in a recent publication. (2) When we looked at process measures that significantly correlated with survival at a facility level, IDT meetings were critical, particularly following sentinel events like hospitalizations. That is fine as far as it goes, but it is now apparent that this is necessary, but not sufficient to get the best outcomes.

Focusing on the holistic needs of the ESRD patient is essential, as demonstrated in the recently completed CMS ESRD Demonstration project.(3)  Attention to preventative care, including immunizations, control of diabetes, fluid overload and aggressive medication management all lead to better overall outcomes. But who is going to relentless pursue these things? The nephrologist?  The dialysis facility core team? We need to expand the definition of the IDT to include additional members, such as advanced practice nurses who cannot replace the nephrologist, but can enhance the team by addressing these key areas of care. If we do, we will truly be walking the walk of team, and our patients will be far better off— withbetter clinical outcomes and higher satisfaction with their care.

If we as nephrologists are to fulfill our responsibilities as leaders of dialysis facilities and clinical care for our vulnerable patients we should remember what the organizations guru Peter Drucker said:

“The leaders who work most effectively, it seems to me, never say ‘I.’ And that’s not because they have trained themselves not to say ‘I.’ They don’t think ‘I.’ They think ‘we’; they think ‘team.’ They understand their job to be to make the team function. They accept responsibility and don’t sidestep it, but ‘we’ gets the credit…. This is what creates trust, what enables you to get the task done.”

I look forward to your comments, until next time.

Striving to bring quality to life,

Allen R. Nissenson, MD

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