Kidney Care Models

Kidney care is the clearest case in American health care of a payment system that funds the outcome nobody wants. Dialysis generates sustained revenue; a transplant or a delayed progression does not. Kidney models exist to invert that.

Kidney Care Choices

The KCC Model “aims to delay the onset of dialysis and incentivize kidney transplantation for people with Medicare who have chronic kidney disease (CKD) stages 4 and 5 and end-stage renal disease (ESRD).” It is voluntary, “launched in 2022 and will run through 2027,” with 73 participants.

The model “brings nephrologists (kidney doctors) and other kidney care providers and practices together to take accountability for patients who have late-stage chronic kidney disease, End-Stage Renal Disease (ESRD), or a kidney transplant, offering coordinated and seamless treatment and care, along with patient education.”

CMS names the problem directly: patients “may experience fragmented care and high-cost treatments that do little to slow disease progression. They also receive limited if any education about their disease and treatment options.”

The intended outcomes are explicit and countable: “reduce the number of patients developing kidney failure, have fewer patients receive dialysis in dialysis centers, and increase the number of kidney transplants.”

Why this design is unusual

Most value-based models ask providers to deliver the same care more efficiently. KCC asks nephrologists to reduce the volume of the service that sustains the sector.

That is a harder ask than it appears, because the nephrologist is often not the party whose revenue falls. Dialysis is delivered largely by a small number of large dialysis organizations, and a nephrologist accountable for total cost may be trying to move patients away from facilities they have long-standing relationships with, or financial interests in.

The introductory course covered the risk spectrum in the abstract. Kidney care is where the abstraction gets concrete: accountability only changes behavior if it lands on the party whose decisions and whose revenue are both in play.

The education finding

The most striking element of CMS’s problem statement is that patients “receive limited if any education about their disease and treatment options.” Patient education is inexpensive, has no clinical downside, and precedes almost every decision that determines whether someone starts dialysis in a center, at home, or receives a transplant.

That it is a named deficiency in a federal model tells you something about what fee-for-service pays for. Nobody bills for a conversation about modality choice.

Worth remembering: kidney models are the strongest available argument that value-based payment is about more than efficiency. The gap KCC targets is not waste in the usual sense, because dialysis delivered to a patient who needs it is appropriate care. The gap is that the system had no mechanism to fund the upstream work, the education and the slowed progression and the transplant referral, that would have made some of that dialysis unnecessary. Fee-for-service does not overpay for dialysis so much as it fails to pay for the alternative at all. Recognizing which of those two problems a model is solving changes what you would expect it to achieve.

Key takeaways

• KCC is voluntary, launched in 2022, runs through 2027, and has 73 participants.
• It targets CKD stages 4 and 5 and ESRD, aiming to delay dialysis and increase transplants.
• The model asks a sector to reduce the volume of its core revenue service, which makes alignment unusually hard.
• CMS identifies limited patient education as a named deficiency, reflecting what fee-for-service does not fund.

Sources

• CMS, Kidney Care Choices (KCC) Model (opens in a new tab)