Seeking necessary treatment can be an overwhelming and confusing experience for patients with Chronic Kidney Disease and End-Stage Renal Disease. As the number of people affected by CKD continues to rise, healthcare providers and patients are faced with escalating costs and grueling treatment plans.
Despite the fact that the mortality rate of ESRD patients on dialysis has steadily decreased to below 25% for Medicare patients, traditional kidney care still leaves room for improvement. While the dialysis space has been a proving ground for increasingly integrated care–the Comprehensive ESRD Care (CEC) Model was introduced by the Centers for Medicare & Medicaid Services in 2017 to experiment with ways to improve care–recently, there has been a push toward adopting such a model for CKD patients as well.
Integrated care is centered on providing a holistic approach to kidney care, and recognizes that myriad factors can contribute to patients’ treatment plans and short, medium, and long-term outcomes. At the center of the integrated care model is value-based care, where healthcare providers are paid based on patient outcomes instead of the number of services administered. Increasingly, integrated care is being seen as a solution to the issues facing kidney care and medicine as a whole.
In an integrated care model, the goal is to address all of a patient’s healthcare needs in one place. This means easier care coordination, fewer logistical burdens, and a better overall experience for patients. Integrated care is a logical shift for CKD because maintaining kidney health involves paying attention to more than just the kidneys. While kidney-specific medications and renal replacement therapies are often part of treatment plans, a comprehensive approach also must take into account the frequently co-morbid diseases that are intertwined with, and often the root of, a patient’s disease progression.
Around 86% of advanced CKD patients experience co-morbid diseases, the most common of which are cardiovascular disease, anemia, diabetes, and hypertension. When treatment for these diseases are added to an already extensive treatment plan for CKD or ESRD, it can impose intense physical and mental strain on patients. Integrated care exists to lessen that strain, by making disease management convenient and simple.
Integrated care is especially useful as a means to reduce oversight and confusion. When care isn’t integrated, a patient sees multiple doctors and has various care plans. Balancing these responsibilities can become overwhelming, and important details can slip through the cracks. In a disease that requires constant monitoring and detailed care, these small oversights can prove to be extremely detrimental to patient health.
On average, a CKD patient takes 19 pills a day. This expansive pill burden is coupled with a medication adherence rate of about 50%. Factors contributing to this low medication adherence include the confusion involved in taking multiple medications, difficulty getting refills, authorization and payment issues, and more. But when an integrated pharmacy program was introduced in a major clinic, there were significantly lower mortality rates and fewer hospitalizations. This highlights how the convenience of accessing treatment may be a key component in realizing gains from an integrated care model. Patients in the mentioned study were given the necessary tools to be consistent in their treatment plan and as a result, their outcomes improved.
In dialysis care, improved outcomes have historically been the result of technological advancements, improved patient education, comorbid disease management, and earlier intervention. With integrated care, patients and their care teams have better access to all of these components, and the outcomes are commensurately improved as well.
Higher rates of chronic disease management are found in integrated care models, including the management of diseases that are commonly comorbid with CKD. Patients are more likely to receive early intervention for depression in integrated care (46.1% vs. 24.1% for traditional care), which can have a dramatic impact on overall patient health and long-term outcomes. Additionally, patients are 39.8% more likely to follow self-care plans and 5.1% more likely to follow diabetes protocols. When care isn’t integrated, a patient has to work harder to access fewer resources at their disposal. One doctor may not know all the answers to a patient’s questions, but having a team of doctors coordinating a care plan can add the extra brain power needed to make tough decisions and diagnoses.
Also, with a shift from fee-for-service care to quality-based measures, physicians are more empowered to find creative solutions. Integrated and value-based care put emphasis on the physician’s role as an innovator and patient resource. With traditional fee-for-service care, physicians are incentivized to maximize payments, which can lead to prolonged treatments and suboptimal patient care. With quality- and value-based care, all the actions taken to treat an issue are linked as one service. Healthcare providers are then paid based on the outcome of that service. The result is physicians that are more focused on efficiently serving a patient’s specific needs.
While the majority of dialysis patients are on Medicare, they only make up about 1% of Medicare beneficiaries. However, dialysis treatment accounts for roughly 7% of all Medicare spending. As the cost of healthcare continues to rise, healthcare providers have been looking to value-based and integrated care as a means of reducing cost.
When care isn’t integrated, patients are less likely to seek treatment for medical issues. With many illnesses, like CKD, it’s difficult to travel to multiple locations to be treated for an extensive list of ailments. With inconsistent care, hospitalization and emergency care rates rise, which both drive up healthcare costs. Integrated care, disease prevention, and management are the goal, reducing the number of emergency services needed and the overall cost burden on the healthcare system.
There are some examples of this already in action. For instance, DaVita Kidney Care’s integrated care division, VillageHealth, saw $75 million in savings by implementing a Comprehensive ESRD Care Model (CEC) as an ESRD Seamless Care Organization (ESCO) during its pilot year. The CEC Model promotes consistent communication between nephrologists, care teams, and patients. This led to a 13% decrease in hospitalizations and per-patient savings of $4,868.
Responsiveness to needs
A benefit of integrated care is that care teams can find solutions for each patient’s specific needs. An integrated care team will have a deep understanding of a patient’s medical history that a traditional care team cannot match. A collaborative environment also allows each member of a patient’s care team (including the patient, family members, and caretakers) to be involved in the treatment process. Members of the team may have limited expertise, but that expertise can be brought together to influence overall treatment decisions based on the patient’s progress.
Also, the importance of provider and medical record continuity cannot be overlooked as influential aspects of integrated care. The consistency provided by integrated care models allows for a trusting patient/physician relationship. Trust is essential because it allows patients and physicians to speak candidly about disease progression and treatment options. While a relationship of this nature should be respectful and professional, it is important that patients share honest feedback about their experiences. It’s especially essential that physicians feel comfortable relaying all pertinent information, both good and bad, to patients and care providers.
For patients on dialysis, a decision often must be made about whether to utilize peritoneal dialysis (PD) or hemodialysis. A study done in China found that most patients were utilizing HD, despite the reduced cost and better protected renal functions in PD. The reasons for the low adoption of PD included both a lack of patient education and lack of insurance coverage. This study found that when HD and PD are used together, in conjunction with patient training and follow up appointments, treatment was more effective.
To effectively switch between PD and HD and help improve patient outcomes, physicians must have a strong sense of a patient’s personalized needs. They must constantly monitor patients’ overall health. This can only happen with trust and provider and medical record continuity, which are pillars of integrated care.
Lastly, integrated care models can help patients to feel more in control of their care plan. A CKD diagnosis can be tough to manage, and many patients may suffer from feelings of hopelessness or depression. Integrated care provides a level of physician-patient communication that traditional care models lack. This means that patients have a greater role in the decision-making process and a greater understanding of their treatment options.
Integrated care puts an emphasis on training and holistic care, which allows many patients to administer part of their own treatment. In many cases, CKD patients rely heavily on others to complete daily tasks due to the physical tolls of the illness. With integrated care, in-home dialysis can be discussed as a serious option without the worries of cost or coverage. And with in-home dialysis, a patient can experience an otherwise unreachable level of autonomy.
As more clinics move toward integrated care, nephrologists and kidney care providers must be ready for change. What’s most essential to the success of integrated care models is empathetic advocacy for patients at all times, as the most effective improvements in the healthcare industry happen when the patient experience is at the forefront.
Divya Chhabra is the COO of Dosis.