"In a time of great advances in kidney care, it's exciting to see Birmingham leading the way in both research and in how care is delivered. Specialty practices across the country are watching Nephrology Associates' transition to value-based reimbursement. The process could become a standard model, and it will be interesting to see how improvements made possible under a quality focus will benefit patients," Adam Boehler said.
Formerly Director of The Center for Medicare and Medicaid Innovation, Boehler was the Senior Advisor for Value-Based Transformation for the Secretary of Health and Human Services. He now serves as CEO of Rubicon Founders and its healthcare partnering company, Evergreen Nephrology.
The transition to value-based reimbursement and away from fee for service began with primary care and is now moving into specialty practices.
"It's a basic shift in perspective," Jeffrey Glaze, MD, with Nephrology Associates PC, said. "Instead of paying for more procedures as the patient gets sicker, the focus of quality-based care is to be proactive to help keep patients healthier. Care provided in this manner focuses on preventing and slowing the progression of kidney disease, pursuing preemptive kidney transplants, and facilitating smooth transitions into dialysis if it becomes necessary.
"We learned a lot from a similar approach working with Medicare. We identified the services that could lead to real change, but under the fee for service model, the time and resources necessary to offer them were not always covered. Partnering with Evergreen Nephrology will allow us to structure our practice to care for patients proactively."
Boehler said, "One of the key problems with the old model is that nephrologists need to be brought in much earlier, when simpler interventions are still able to limit or at least slow down the damage."
Glaze added, "We need to educate patients so that they understand how both the length and quality of their life depend on what they are doing now. It's going to take more one-on-one interactions to keep them on course and to spot potential problems early. It doesn't always have to come from a physician. It may be a home visit by a nurse practitioner following up a hospital discharge, or a nurse calling to check on a patient's blood pressure. It could be a social worker checking on a patient's home environment or a dietician offering dietary advice that will help control diabetes, hypertension, and prolong kidney health."
Boehler said, "The goal is to prevent a crash that might precipitate the need for dialysis or to postpone it as long as possible. If the day comes when it is clear that dialysis will be needed, patients will be given support and more education to understand their options."
The news that a patient's kidneys are going to need help doesn't necessarily mean he is doomed to spend much of his weekly waking hours attached to a machine at a dialysis center. Peritoneal dialysis at home can be a good option for many patients. In this case, the patient can treat himself during sleep, freeing up time for other things. This also means that transportation won't be a problem, and if he has other health problems with a weakened immune system, he can stay safe at home.
"We also make sure patients understand early on that the best time for many people to receive a kidney transplant is before reaching a point of needing dialysis," Glaze said. "We teach them about transplant lists and steps they can take to increase the odds of finding a living donor if they need one."
Once a patient's kidneys become severely damaged, the odds can go against them quickly. There are thousands more people on the waiting list than the number of donor kidneys available, and every year many die waiting for a match that doesn't come, or they get moved off the list because their health has deteriorated too much for a transplant to succeed.
"This is one more example of why it's important to focus on keeping patients as healthy as possible," Glaze said.
The partnership between Evergreen Nephrology and Nephrology Associates is now working on the details of ramping up to launch the transition to a value-based reimbursement structure. While Boehler and Evergreen negotiate with insurance companies and other payers, Nephrology Associates is staffing key positions and building infrastructure.
"If you don't change the way you do things, outcomes won't change either," Glaze said. "We're changing to give our kidney patients the very best care we can deliver and a better chance at a good quality of life."