Has the kidney care industry finally entered a new era? New industry insights and a focus on a startup’s journey suggest a change is coming. We are finally seeing new ways and resources to help physicians who have long been plagued by frustrating outcomes, high-cost care inefficiencies and misplaced incentives in the Battle of Sisyphus.
when In 1972, Medicare made the unprecedented decision to expand coverage to anyone who needed dialysis to stay alive, it creates an opportunity for special interest groups to compete for dollars tied to policy changes. It also provides a monetary incentive to treat only the most seriously ill. Decades later, The result is a highly integrated industry of dialysis providers This exerts enormous market power to negotiate inflated reimbursements. These large dialysis providers have little need to compete on quality or prevent the progression of early-stage kidney disease, which would keep patients away from their centers, despite the enormous burden placed on patients and their caregivers by the three-week, four-hour sessions.
Although primary care providers and nephrologists have so far been calling for help preventing kidney disease progression, the current standard of care encourages the treatment of patients who already have kidney failure (end-stage renal disease, or ESKD). ) at a profitable dialysis center. This paradigm ignores the significantly larger population of chronic kidney disease (CKD) patients who are at high risk of developing ESKD without appropriate intervention.
The negative effects of this distorted system are evident when patients have a poor prognosis. Many patients are not referred to a nephrologist until stage 4, just before kidney failure requires dialysis. About one in five people with ESKD do not survive within a year, and 50% die within five years of onset. According to the American Kidney Data System, kidney transplant rates in the United States have actually declined by 25% over the past 20 years. Additionally, the U.S. ranks 10th among peer countries for peritoneal dialysis (PD)a more convenient and cost-effective way to do it at home.
To address the challenges facing the industry, policymakers and entrepreneurs alike are developing complementary strategies to help primary care physicians, nephrologists and other care team members disrupt the status quo. On the policy front, two major policy updates are paving the way for change.
first, Center for Medicare Innovationter has developed a range of novel payment models for the nephrology community and its entrepreneurial partners. These models create strong economic incentives to manage the care of CKD beneficiaries to delay the onset of ESKD, encourage more cost-effective and safer treatment modalities such as PD, and incentivize kidney transplantation.
Second, the launch 21st Century Healing For the first time in 2021, ESKD patients will be able to actively enroll in any private Medicare Advantage (MA) plan. This change gives patients the flexibility to choose the plan that best suits their needs and inspires MA plans to develop innovative strategies to better manage renal care patients and keep them healthy. This change also motivates MA programs to develop or in-house strong care management programs to manage this complex population, as these programs will take financial responsibility for thousands of ESKD patients for the first time ever.
Amid this changing regulatory environment, a startup is seeing early traction in bringing innovative population health strategies to kidney care patients. Somatus (Flare Capital portfolio company). Founded in 2016, Somatus Partner with health plans, provider practices and regulators to develop new models of care and manage the care of more than 120,000 patients in more than 30 states.
The company utilizes advanced predictive analytics and risk stratification techniques to identify patients at highest risk for CKD progression. Somatus’ system alerts field care teams, allowing them to tailor targeted interventions to patients in the community. Interventions aim to proactively slow the progression of kidney disease. This is achieved by investing in preventative care for costly end-stage renal failure crisis management. In addition to evidence-based chronic disease management, this package of interventions may include education about cheaper home dialysis modalities and transplant referrals for patients with kidney failure.
By tracking industry-standard quality and outcome metrics, including HEDIS and STARS scores, Somatus has seen significant improvements in both cost and quality outcomes for its patients. For some members, the company saw an 18% reduction in healthcare costs, a 34% reduction in inpatient utilization and a 12% improvement in medical loss rates.
Of course, Somatus isn’t the only company looking to disrupt the kidney care industry. Others, such as Cricket Health, are also making progress. Cigna Ventures and Blue Shield of California both invested in Cricket Health’s Raised $83.5 million last year. In fact, both payers cited improved outcomes as a reason for their investment. Cricket Health’s Kidney Care Program uses digital care solutions, education, and virtual and telephone care team support to help kidney disease patients nationwide manage their disease.
However, these young companies will all face similar challenges.They must navigate a fragmented care delivery system in which patients’ primary care physicians, nephrologists, other specialists, and dialysis centers are not empowered to talk to each other effectively (an ongoing challenge, and other Federal shifts such as implementing Trusted Exchange Framework and Mutual Agreement 2022, working on it). They will deal with a regulatory environment that has been slow to respond to changes. In the end, they will have to compete with large dialysis organizations that resist change, have strong lobbies, and hold a significant share of the national nephrology community.
However, we can hope that with the support of players like Somatus and other young kidney care start-ups, the industry is moving in the right direction on the back of significant regulatory tailwinds.
Photo: peterschreiber.media, Getty Images
