Recent headlines have sounded alarms about the increase in the number of unfilled nephrology fellow positions. According to the American Society of Nephrology, there were 0.60 applicants per position for 2016––a 62% decline since 2009 (see Figure 1). Over the past few years, this has raised concerns of a nephrologist shortage, and many have looked to find ways to understand the cause. Does the new generation of nephrologists demand a different post-graduate lifestyle? Is low demand for fellowship positions driven by poor financial incentives? Expanding student debt?
These are interesting questions. However, they seem directed at maintaining the status quo. Perhaps we should be asking other questions, ones that will help nephrologists best use their skills to succeed in a new era of health care.
Saving our profession
After the 2015 fellowship match numbers were released, Kristina Fiore of MedPage published a telling piece: “Match reveals no love for nephrology.” In the article, nephrologists pointed to lifestyle and compensation as reasons for dwindling interest in our field. That article was preceded by a 2013 blog post from Allen Nissenson, MD, chief medical officer of DaVita Kidney Care, who asked, “Where have all the nephrologists gone? Long time passing!” Both of these pieces ask why a nephrologist shortage exists and offer potential solutions. I read them both with great interest. After all, this is the future of nephrology. But I wondered: Are we looking at this problem through the lens of what we know, destined to come up with solutions that are comfortable to us? Should we look at this problem differently?
I would argue the answer is yes. Despite dramatic changes in how care will be reimbursed, let’s accept that little has changed in the past 100 years as to how health care is delivered. It is delivered one-on-one. Patients schedule appointments, see doctors, and arrange follow-up appointments. Yes, we now have electronic medical records (EMRs)–– the power of data driving our decisions––but in the end, the bottleneck remains at the point of care.
These manpower issues are not new and certainly not unique to health care. The titans of industry driving the industrial revolution at the turn of the 20th century also struggled. Ultimately, innovation and “thinking differently” separated the successes from the failures. Industry leaders moved from highly specialized craftsmen, who created products at high cost and often inferior quality, to systems that embraced processes and procedures. This new way of business focused not on the craftsmen, but rather, the product. Today, industries continue to adapt, transforming themselves to deliver high-quality service at lower costs. From Henry Ford to Uber, elements of these models are easily transferable to nephrology and are already making their way into other areas of health care. We nephrologists are the “Henry Fords.” So what are our next steps to revolutionize our industry?
It’s all about teamwork
By 2018––just two years from today––the federal government wants to have 80% of its Medicare fee-for-service payments in risk arrangements, meaning that in order for physician practices to survive, nephrologists must move toward an oversight/leadership position.1 This will free up more time to focus on quality, process, and practice retooling. There is some good news: the model already exists. The majority of dialysis facility medical directors, myself included, use a team-based approach to delivering patient care at a population level, with individual patient care delivered by others. Not only is this model successful, but it also has contributed to the improvement we have seen in kidney care. This team approach has been incorporated into other fields of medicine as well, including emergency room care. Is this model applicable to the general practice of nephrology? I believe it is. But the Emperor may be wearing new clothes.
The nephrology practice of the future, now
The successful nephrology practice of the future will require the following:
- Increased use of non-physician providers, not only in dialysis facilities but also in office/clinic and hospital settings.
- Development of “nephro-hospitalists.”
- Expanded use of electronic medical records, information technology, and telemedicine.
Let’s explore each of these innovations.
Non-Physician Providers (NPPs)
The majority of kidney care is predictable, quantifiable, and easily managed using clinical practice guidelines (CPGs). CPGs exist for chronic kidney disease care, dialysis care, hypertension, and kidney stone disease, just to name a few. Unfortunately, these evidence-based guidelines, which are accepted worldwide, are severely underutilized. This results in unnecessary variations in care, which is especially problematic as reimbursement shifts from a fee-for-service to a risk-based arrangement.
Utilizing non-physicians providers––physician assistants and nurse practitioners–– guided by practice guidelines in the office/clinic and dialysis facility creates tremendous capacity for nephrologists. Indeed, following an initial visit/consult and diagnosis, patients should be turned over to the NPPs chronic kidney disease clinic for follow-up care, with nephrologist oversight. This increases the clinical capacity two- or three-fold. The same is also true for the dialysis facilities. Using robust electronic medical records, patient satisfaction surveys, and other tools, quality metrics and patient outcomes are easily tracked and measured to ensure goals are being met.
The use of nephro-hospitalists is not a new concept, but one that is underutilized and worth discussing. Are you tired of trying to be in three places at once? Under pressure from hospital administrators to “move patients through” the hospital stay quickly? Hate early-morning and late-day urgent consults? Wondering how your practice will meet the hospital demands imposed by risk contracts? A nephro-hospitalist may be the answer, particularly for mature practices with established referral patterns and robust patient populations.
The concept is relatively simple. New fellow graduates (many of whom choose hospitalist work for financial reasons) would serve as hospital-based nephrologists representing the practice. They would have fixed hours; be able to quickly and efficiently see consults, and do rounds with existing patients. In addition, they would be able to develop and maintain relationships with intensive care, cardiac, emergency room and primary care hospitalist staff. Their presence would free up senior nephrologists to focus on restructuring the practice as necessary.
Expanded use of EMR, telemedicine
More than 85% of practices now have EMRs, and for the majority of us, they are a one-way street. We put data in but get little back. Given the increased focus on population risk management and measuring quality, getting the full use out of EMRs is essential. Aggregating this data at local, regional and national levels — similar to what is done with end stage renal disease data — is also critical. The Renal Physicians Association, along with EMR vendors, have developed registries to accomplish this. Senior practice staff, now freed up by using physician extenders and nephro-hospitalists, can better focus on these issues. Another way to help modernize our industry is by expanding the use of telemedicine, a practice that is growing and is reported to become an $18 billion business by 2020.2 Payers and patients are slowly accepting it, and its use in remote care settings should be viewed as an efficient way to treat underserved populations.
Pulling it all together
Incorporating these changes will elevate nephrologists to the position of overseeing the care of kidney patients and leading quality population management. It also will allow senior practice physicians to focus on the restructuring necessary to cope with the evolving requirements of risk management. Each practice will move in this direction based on regional factors, as well as internal practice dynamics. The transition doesn’t have to be disruptive, but rather, incremental. Figures 2-5 represent some of these changes in the office/clinic, IT/EMR, dialysis facility, and hospital settings.
There is no one-size-fits-all solution that will work for every practice. Rather, we should focus on a philosophical paradigm shift from direct caregiver to the leader of the kidney care team in the broadest sense. I want to be clear: Using nephrologists solely for direct provision of patient care undervalues our skills and limits the delivery of care. Expanded training and use of nephrology physician extenders and incorporation of nephro-hospitalists are important steps forward to better utilizing our skills, given patients’ and payers’ new expectations. We are highly trained professionals with the knowledge and skills to determine the future of our specialty and the care of our patients. Let’s do so.
- Health and Human Services. Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html
- 2 Hall SD. Fierce health IT. Rapid growth projected for global telemedicine market. http://www.fiercehealthit.com/story/rapid-growth-projected-global-telemedicine-market/2015-05-20