The National Kidney Foundation has proposed a new system of bundled Medicare payments to primary care practitioners and nephrologists in an effort to encourage earlier detection and optimal management of chronic kidney disease.

“If we really want to lower Medicare payments for kidney patient care, we need to make sure early detection and management of CKD is incorporated into the Medicare system,” said Tonya Saffer, MPH, Senior Health Policy Director of the National Kidney Foundation. “The members of the Senate Finance Committee workgroup have a great opportunity to improve outcomes and lower healthcare costs by specifically including CKD bundled payments and co-management into their chronic disease care proposals.”

The proposal was delivered to Senators Johnny Isakson, R-Ga., and Mark Warner, D-Va, both members of the Senate Finance Committee, in response to the committee’s plan to address chronic disease care. The goal of the Committee’s workgroup is to identify ways to lower healthcare costs and improve care for individuals with multiple chronic illnesses.

“We believe that specifically addressing CKD care and costs upstream is imperative to reduce cost and secure better outcomes for chronic disease patients,” said Saffer. “CKD is unique because it’s very cost-effective to treat in its early stages, but if it goes undiagnosed, the comorbidities and costs rise dramatically.”

Medicare spends $87 billion annually to care for patients with kidney disease, with $58 billion spent on individuals with CKD stages 1-4 (prior to stage 5 end stage renal disease or kidney failure). An Avalere Health analysis of 2013 data found that Medicare spending on CKD patients is 2-7X higher than spending on the average Medicare beneficiary. Many published studies conclude that identifying and managing CKD earlier could reduce comorbidities and hospitalizations, resulting in healthcare savings.

NKF’s proposal to address CKD within the Medicare system hinges on five recommendations from NKF to the Senate Finance Committee. These recommendations direct the Secretary of Health and Human Services (HHS) to:

  1. Work with organizations and health care practitioners to develop a bundled payment model that links Medicare reimbursement to quality measurements of improvements in early detection and management CKD for primary care practitioners.
    1. Incorporate testing for CKD in those at risk, using a urine albumin to creatinine ratio and a serum creatinine to estimate kidney function into the recently announced Million Hearts: Cardiovascular Disease Risk Reduction Model. These tests have been shown to independently improve prediction of cardiovascular disease in general and particularly heart failure and death from heart attack and stroke.
    1. Work with experts in evidence-based clinical practice guidelines to develop a capitated payment model for nephrologists for the management of CKD stage 4 patients and to identify and/or develop quality metrics that can be tied to the nephrologist’s reimbursement.
    2. Pilot a Medicare payment model for co-management of patients with advanced CKD, who do not have ESRD. The greatest potential for significant cost savings are achieved when a PCP and nephrologist co-manage patients with advanced CKD (stage 4). Such a payment model could facilitate best practices and shared savings to the PCP, nephrologist, and the government.
    3. To remove barriers, beneficiary copayments and coinsurance for services related to CKD management should be waived or reduced. Services such as medical nutrition therapy and kidney disease education services should also be more broadly available as an option through telehealth.

    NKF’s proposal is unique in that there are currently no alternative payment models to address CKD and incentivize early detection of CKD. Some private providers do offer programs to prevent patients from developing kidney failure, but these programs are usually reserved for late-stage kidney patients.