The traditional fee-for-service (FFS) healthcare model isn’t well-suited to meet the complex needs of patients with chronic illnesses including chronic kidney disease (CKD). As costs spiral and population health declines, value-based care (VBC) presents a solution that can reshape how the healthcare system approaches CKD management and can serve as a model for how we treat other chronic diseases.
The nephrology field faces significant challenges, especially with the increasing cost of caring for patients with multiple health conditions. The FFS model is not fulfilling the needs of these chronically ill patients and incentivizes the quantity – not the quality – of care given, leading to frequent hospital visits and readmissions. VBC presents an alternative approach, incentivizing providers to maintain patients’ health instead of reactively addressing complications after they happen.
This shift toward preventive, coordinated care can help address physical and social factors that influence health outcomes, enabling nephrologists to work more effectively with their patients. Given the shortage of kidney specialists and their many responsibilities across various healthcare settings, value-based models can provide the resources and support systems that can make efficient and effective chronic disease management possible.
The current kidney care landscape and its limitations
CKD affects over 35 million Americans and accounts for more than 24% of Medicare’s entire budget. Under the FFS payment model, providers earn money based on services they deliver instead of the quality of results achieved. This creates incentives that favor treating complications rather than preventing them. Since CKD patients are often required to bounce between different specialists for their conditions, duplicate tests, conflicting treatments, and missed opportunities for comprehensive care are common occurrences.
By tying incentives to patient outcomes, preventive services, and cost-effectiveness, adopting a VBC model could help solve this systemic flaw. Rather than rewarding volume, value and quality would be at the forefront. This shift would ultimately address the root problems that make the current kidney care model both expensive and ineffective.
Managing conditions separately results in fragmented care that fails to address patient needs, especially since those conditions are interrelated. Commonly overlooked areas relate to underlying inequities such as income, education, food security, and transportation. These all are contributors to higher risk for the earlier onset and more rapid progression of kidney disease, which further emphasizes the failures of a siloed approach to care.
Challenges with increasing the nephrologist workforce
The nephrology workforce shortage represents another one of the biggest obstacles to offering more optimal kidney care, as there are not enough specialists to meet demand. This shortage stems partly from geography, since newly trained nephrologists typically gravitate toward urban areas, while rural communities go underserved.
Medical students often lack exposure to outpatient nephrology during their training, and misconceptions about managing complex, chronic conditions and career prospects including income opportunity and work-life balance discourage the pursuit of the specialty.
These workforce limitations need creative solutions, and VCB can play a role. In VBC, the nephrologist is the leader of a multidisciplinary care team. These interdisciplinary teams (IDT) include advanced practice providers, nurses, dieticians, pharmacists, and social workers, extending the reach and effectiveness of nephrologists in providing comprehensive care. Technologies like telemedicine can also bridge geographic shortages, bringing specialists’ and the IDT’s expertise to patients no matter their location.
VBC models can improve work-life balance, adding a new income stream and reducing physician burnout. Nephrologists can focus on prevention and building patient relationships, rather than churning through high-volume appointments. As job satisfaction improves, there will be more interest in the nephrology profession among trainees.
The kidney care policy landscape
Healthcare funding shapes the way providers in the industry operate. The Centers for Medicare & Medicaid Services (CMS) shapes how kidney care is delivered in the U.S. through payment policy because more than 80% of U.S. residents with end-stage kidney disease have either traditional Medicare or Medicare Advantage insurance and CKD disproportionately impacts the elderly. The current FFS payment model employed by CMS has led to dramatic growth in healthcare costs especially in patients with complex chronic diseases such as CKD.
The Kidney Care Choices (KCC) Model was created by the Centers for Medicare and Medicaid Innovation (CMMI) to transform kidney care delivery and show how policy changes can create incentives for better outcomes with controlled costs. From reducing progression to kidney failure and increasing home-based treatment options to expanding access to kidney transplantation, this model has reshaped financial incentives for providers and encourages them to focus on helping patients live longer, healthier lives.
The early results from the KCC model are promising, showing significant improvement in patient outcomes. Many Kidney Care Entities (KCE) within the model are driving Medicare savings, but the impact on overall costs to Medicare is yet to be determined. CMMI recently announced the Comprehensive Kidney Care Contracting (CKCC) program in the KCC model will be extended through 2027 to continue to collect data on the overall program impact. As KCEs continue to focus on health maintenance and prevention, hospitalization and other costly overutilized services are anticipated to be reduced.
Enabling a value-based future
The future success of nephrology care will depend on early detection and prevention strategies that can slow disease progression. This will require the screening of high-risk populations paired with quick intervention when problems arise. Technology will also play an increasingly important role in this transformation, with systems like remote monitoring enabling continuous tracking of patient health to avoid frequent office visits and artificial intelligence identifying patients at highest risk for complications. Both of these innovations can help enable targeted interventions and prevent costly emergencies.
Addressing health disparities must become a priority, too, since kidney disease disproportionately affects certain populations. A VBC model will help, as it incorporates addressing social determinants of health into treatment planning and creates incentives for improving outcomes within underserved populations.
A systemic change from FFS to VBC would represent more than a payment model switch, but rather a holistic transition toward patient-centered healthcare that prioritizes outcomes over activity. Long-term success will require collaboration among policymakers, healthcare providers, and patients, so nephrology can set the precedent for how coordinated preventive care creates better outcomes while controlling costs.
Photo: peterschreiber.media, Getty Images
Dr. Tim Pflederer is the Chief Medical Officer of Evergreen Nephrology. Dr. Pflederer has spent 30 years caring for patients with kidney disease, in addition to serving as past president of the Renal Physician Association, and other organizations committed to improving healthcare at the national level. He is an experienced physician leader and clinician with experience in general and interventional nephrology, dialysis facility quality and safety, value-based care, coding and billing, and local and national advocacy for nephrology practices and patients.
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