Chronic Kidney Disease Stakeholder Summit

The impact of chronic kidney disease (CKD) on patients and the health care system in the United States is substantial and expected to increase with the expanding obesity-driven diabetes epidemic.¹ Individuals with CKD frequently experience concurrent conditions such as type 2 diabetes (T2D), cardiovascular disease (CVD), and heart failure (HF), complicating disease management and contributing to high costs of care. During a recent AJMC Stakeholder Summit moderated by Ryan Haumschild, PharmD, MS, MBA, a panel of experts described the clinical and financial challenges associated with early CKD identification and management with guideline-directed therapies. The panel recommended practical solutions for overcoming barriers from a provider and payer perspective to facilitate comprehensive and cost-effective patient care for optimal disease outcomes.

Burden of Disease

Defined as a persistent abnormality in kidney structure or function for more than 3 months, CKD affects approximately 8% to 16% of the global population.^2,3 Kidney abnormality is identified from laboratory indications of reduced kidney function, namely the ratio of urine albumin to creatinine (uACR) exceeding 30 mg/g or an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m². To assess prognosis and implications for health, CKD is stratified from these measurements using the Kidney Disease: Improving Global Outcomes (KDIGO) risk classification system.² Based on single measures of eGFR and albuminuria, the National Health and Nutrition Examination Survey results estimated that 14% of adults in the United States have CKD, translating to approximately 31.2 million individuals.⁴

Diabetes and hypertension are the primary causes of CKD in individuals in middle- to high-income countries.³ The renal, metabolic, and cardiac systems are intricately interconnected, together maintaining homeostasis within the body.⁵ An increasing body of evidence has highlighted the association among CKD, T2D, and CVD, termed cardio-metabolic-renal disease, to convey their interdependence.⁶ The heart relies on the kidneys to regulate fluid balance, and the kidneys depend on the heart to provide an adequate blood supply.⁵ Over time, hyperglycemia can lead to damage in both the kidneys and the heart.⁷ Given their shared roles in maintaining overall metabolic and circulatory health, CKD, T2D, and CVD often coexist, and their co-occurrence leads to increased morbidity and mortality.⁵ For example, individuals with HF are 4-fold more likely to have T2D than those without HF, and having T2D is linked to a 2- to 4-fold elevated likelihood of developing CVD.⁶ Among individuals with T2D, the prevalence of CKD is approximately 40%; among those with HF, it is approximately 50%.⁶ Furthermore, CVD is the leading cause of death among individuals with CKD, causing 35% to 45% of fatalities in this population.⁸

Accordingly, health care costs associated with CKD in the presence of T2D, CVD, and HF comorbidities are substantially higher than for CKD alone.^1,4 In 2021, 13.5% of Medicare fee-for-service beneficiaries 66 years or older had a diagnosis of CKD. Despite this relatively small percentage, these individuals accounted for nearly 25% of the total Medicare fee-for-service spending.⁴ Approximately 60% of beneficiaries with CKD had concurrent diagnoses of diabetes, HF, or both, and this subgroup was responsible for approximately 70% of the total costs incurred by individuals with CKD.⁴ Similarly, an electronic health record (EHR) analysis among patients with CKD demonstrated patterns of increasing total health care costs by progressing CKD stages and increasing comorbidity burden.¹ Patients with CKD alone incurred the lowest costs, whereas those with CKD and HF incurred the highest.¹ Costs for patients with diabetes and CVD comorbidities were also substantially higher than costs for managing CKD alone.¹

Stakeholder Insights

Susanne B. Nicholas, MD, PhD, MPH; Jennifer B. Green, MD; Ken Cohen, MD; and John E. Anderson, MD, joined Haumschild to discuss the burden of CKD from medical and economic perspectives. Nicholas provided a brief overview of the increasing prevalence and incidence of CKD, emphasizing that CKD is a significant public health issue in the United States and worldwide with a substantial morbidity and mortality risk, particularly when it comes to CVD. She explained that staging patients allows for risk stratification for kidney failure and CVD to ensure providers can initiate the appropriate therapies.

Utilizing an extensive CKD registry in the United States, Nicholas and colleagues measured the incidence of CKD in patients with diabetes and determined the incidence rate ratio for different racial and ethnic groups.⁹ The study findings revealed that Native Hawaiian or other Pacific Islander individuals have the highest incidence rate ratio, followed by Black and African American individuals, Alaska Native and American Indian individuals, and Hispanic individuals. Nicholas concluded that “these are racial and ethnic minority groups who have very high risk for [CKD], [representing] the groups whom we really should be focusing on.” Haumschild reiterated the increasing incidence of CKD, noting an interplay among CKD, CVD, and T2D. Green explained that although we tend to think about the 3 diseases as separate, there is “a tremendous amount of overlap, and it’s very common for a given individual to have all these problems or at least more than 1 of them,” adding that the risk of adverse outcomes is compounded when comorbidities are present.

Haumschild pointed out that the occurrence of these comorbidities also affects the cost of care. Cohen explained that in 2019, Medicare spent $89 billion managing CKD, noting that “crashing into dialysis is a very expensive way of entering renal replacement therapy for those who haven’t been identified in advance.” Cohen added that the presence of comorbidities and progressing disease further drive these costs. Haumschild reflected that “if we don’t invest in identifying these patients early and stop that progression of disease, there could be greater costs on the horizon.” Because T2D is the primary driver of CKD progression and more than 90% of patients with T2D in the United States are treated by their primary care providers (PCPs), Anderson explained that PCPs “really have the opportunity to be on the front line of [treating] these people.”

Early CKD Identification and Intervention

CKD Screening

Reduced eGFR and increased albuminuria are independently associated with risks for adverse outcomes, such as progression to kidney failure, CV events, and death.¹⁰ Therefore, both eGFR and uACR should be measured to inform prognosis and direct care for CKD.^10,11 Both KDIGO and American Diabetes Association (ADA) guidelines recommend routine screening for CKD as part of the management of high-risk conditions such as diabetes, hypertension, and CVD to allow for early identification of kidney damage.^2,11,12 Early CKD staging permits cardio-renal protective interventions, which have the potential to significantly reduce the adverse health effects of CKD.^2,11,12 However, implementation in clinical practice is lacking, leading to suboptimal clinical care and outcomes.¹² For example, less than 50% among patients with diabetes and less than 10% among those with hypertension without diabetes were tested for albuminuria.⁴ Consequently, early-stage CKD often goes unrecognized, representing a missed opportunity for intervention when preventive measures could be most impactful.¹²

Guideline-Directed Therapy

Renin–angiotensin system (RAS) pathway modulators, specifically angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), have been the standard of care (SOC) for kidney preservation, and they are recommended for patients with albuminuria and hypertension.^2,10,13 More recently, several new renal-cardiac protective therapies offer benefit in addition to RAS inhibition.^10,13 Among these therapies, sodium-glucose cotransporter 2 (SGLT2) inhibitors were initially designed to lower blood glucose levels in individuals with diabetes by inhibiting the reabsorption of glucose in the proximal tubules of the kidneys.¹⁰ Fortuitously, SGLT2 inhibitors also substantially reduce proteinuria, benefiting renal hemodynamics, as evidenced by an immediate decrease in eGFR followed by the stabilization of kidney function.¹⁰ According to the KDIGO guidelines, SGLT2 inhibitors should be initiated when eGFR is 20 mL/min/1.73 m² or higher in patients with or without T2D.¹³ Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) can be utilized as an alternative glucose-lowering therapy if SGLT2 inhibitors and metformin are unable to be used or insufficient to meet glycemic targets.¹³ Patients with T2D with persistent albuminuria despite treatment with RAS modulators and SGLT2 inhibitors are at high risk of CKD progression and CV events; they should be given a nonsteroidal mineralocorticoid receptor antagonist in addition to those frontline therapies.¹³

Barriers and Potential Solutions to Using Guideline-Directed Therapy

Despite high-quality data supporting the benefits of cardio-renal protective agents, these therapies are not reaching the patients at highest risk.¹⁴ Multiple barriers to early identification and treatment of CKD in primary care have been reported, including limited knowledge of CKD and its complications as well as low awareness of guidelines.¹² Furthermore, busy primary care practices may have limited time or clinical support to care for patients with CKD.¹² Also contributing to treatment hesitancy may be the tendency for providers to operate in isolated or disconnected ways, known as siloed care.¹⁴ For example, cardiologists and nephrologists may be reluctant to initiate SGLT2 inhibitors because they require adding diabetes management to existing subspecialist responsibilities, adjusting antidiabetic therapies prescribed by other physicians, and handling financial concerns such as prior authorizations, inadequate insurance coverage, and excess out-of-pocket cost issues.¹⁴

Incentivizing physicians to build a population health framework can lead to improved outcomes, as demonstrated in findings from a recent study comparing a Medicare fee-for-service payment model with a 2-sided risk model, in which physicians assumed financial risk for total cost of care.¹⁵ Similarly, the Merit-based Incentive Payment System (MIPS) is designed to incentivize high-quality care and reduce health care expenses by administering financial benefits and penalties to participating clinicians.¹⁶ Additional strategies to overcome barriers to CKD management include implementation of multidisciplinary care models, structured risk mitigation strategies, multidisciplinary education, and harmonization of clinical practice guidelines.¹¹

Stakeholder Insights

Clinical and Financial Considerations
for CKD Screening

Anderson explained that cardio-renal-metabolic screening is of the utmost importance for the early identification of patients with CKD. He noted that measuring the uACR is often overlooked but essential for identifying microalbuminuria, which frequently precedes a decrease in kidney function. Haumschild agreed, noting that creating awareness among payers and PCPs can facilitate earlier detection of CKD. Anderson added that because patients with CKD often have comorbidities, their providers typically practice in silos based on their specialty, such as cardiology, nephrology, and endocrinology. Anderson emphasized that practitioners must work together to maximize care, noting that “anybody who has a touchpoint with these patients does not get to abdicate responsibility for their care.” Green echoed the shared responsibility of managing cardio-renal risk, noting “management of risk is often treated as a hot potato…tossed to the next doctor that the individual is going to see. We need to stop and take the time to understand our patient’s risk and either recommend the interventions ourselves or engage the other providers directly.”

Nicholas explained that screening for CKD is not routine, underscoring the importance of identifying patients at risk for CKD development. Risk factors that practitioners should be aware of include vulnerable racial and ethnic populations, patients older than 65 years, and those with a history of diabetes, hypertension, or a family history of CKD. Once patients at high risk are identified, they should be screened for CKD by measuring uACR and eGFR and risk stratified using the KDIGO heat map to indicate how they will progress over time. Nicholas emphasized that “having both [uACR and eGFR] puts the provider and the patient in a wonderful position to know where they stand in terms of their level of kidney function and risk for progression so that the…[SOC] may be implemented.” Green responded that annual uACR testing is not often performed in patients with T2D despite the decades-long recommendation, indicating a failed appreciation of the CKD risk in patients with T2D. Green explained that screening allows for early intervention in both the course of disease and the patient’s life span: “We need to be very cognizant of the fact that, in this country, people are developing [T2D] or these other complications at very young ages.” Green concluded that “there’s a misconception that [young patients affected by T2D and CKD and/or CVD] are not at great risk. In fact, their risk is greatest over their lifetime, and they need to be identified as at risk and treated appropriately.” Intervening early in the disease progression and early in the patient’s lifetime allows for maximum preservation of kidney function.

To implement these practices, Nicholas noted that the ideal program would convene “the multidisciplinary team together, where [everyone] can have an input [on] that patient in terms of their diagnosis of CKD, their risk of progression, the medications that they need, and all the ancillary things that are needed to…[ensure the] patient’s care is optimized.” Nicholas recommended telemedicine and e-consultations to connect the members of the care team, such as specialists, pharmacists, nutritionists, and diabetes educators, adding that “there are a number of other ancillary care individuals who are needed when it comes to providing optimal care for patients with [CKD], primarily because there are so many additional complications that can occur in these patients.”

From a payer perspective, Cohen outlined ways to encourage CKD screening among health care providers, including as follows:

• Shifting from small practices to more sophisticated care models that include care managers
• Using a 2-sided risk payment model
• Utilizing at-home uACR and eGFR testing kits to lessen PCP burden
• Implementing transparent reporting of screening
• Providing comprehensive financial incentive models

Cohen elaborated on the 2-sided risk payment model, noting that “shifting that responsibility, both clinically and financially, to a physician organization creates a compelling indication to move upstream, begin to risk stratify, and try to get earlier into the disease process.” Cohen explained that transparent reporting of screening is also effective because “physicians, NPs [nurse practitioners], and PAs [physician assistants] are very competitive by nature. And transparently reporting results of screening is a very potent change agent; nobody likes to be at the bottom of those lists.”

Anderson added that educating the providers in the primary care system is also critical to improving screening for CKD. Historically, treatments weren’t available to prevent worsening of CKD, so there was little value in screening. With the availability of CKD therapies, the primary care community must be educated to adopt screening. Anderson concluded, “We have something to offer our patients [with CKD that] we haven’t had for years. But it’s also a little bit of a stick. You need to do this, and you are going to be judged and financially rewarded based upon whether you’re doing the right thing for your patients.”

Managing CKD in the Presence of Coexisting Conditions

Nicholas explained that managing CKD involves controlling diabetes and hypertension to prevent kidney damage, with ACE inhibitors and ARBs being the SOC. Newer therapies, such as SGLT2 inhibitors, have drastically improved outcomes by providing both kidney and cardiac protection, leading to a reduction in premature mortality by approximately 15 years, she said. Nicholas added, “It’s a new era…because we have something that we can offer our patients that we didn’t have previously [with] both cardiac and kidney protection.… This is a wonderful time for providers, but it’s an even better time for our patients.”

Haumschild and Green discussed the continuum of care in managing CKD in the context of coexisting conditions. Green explained that it’s important to understand that there is substantial overlap between CKD and CVD damage, and both diseases progress along the same timeline: “These are almost one and the same process and not necessarily separate complications, although that’s how we handle them.” Green added that the CV risk associated with advanced CKD is such that many individuals with advanced CKD die of a CV event before they ever need dialysis. Furthermore, patients with CKD and T2D have a higher risk of complications throughout the body affecting multiple systems, such as diabetic retinopathy, peripheral neuropathy, and peripheral vascular disease, and as CKD worsens, it becomes difficult to manage their hypoglycemia safely.

Nicholas said that newer CV and renal protective agents can be added to the SOC to improve outcomes for individuals with persistent risk of CKD progression: “These individuals would be ideal for adding the newer nonsteroidal mineralocorticoid receptor antagonist, the one that right now is approved by the FDA within the United States. It is called finerenone [Kerendia] and has been shown to provide additional cardiac and renal protection in individuals who are even at significant risk.” Nicholas added that guidelines and algorithms direct how to initiate these therapies and how to manage complications. From a payer perspective, Cohen reflected that it is essential to consider value-based care and the cost-effectiveness of any therapy, reiterating the importance of early intervention to utilize cost-effective SOC drugs, which often lose their beneficial effect as CKD progresses.

Green explained that ADA guidelines recommend patients with T2D and any evidence of CKD receive an SGLT2 inhibitor in addition to their RAS inhibitor. Green noted that “SGLT2 inhibitors should be part of their foundational therapy, primarily to reduce the risk of progression of kidney disease and to reduce the risk of major adverse CV events, including heart failure.” The GLP-1 RAs are recommended for risk reduction as an alternative to SGLT2 inhibitors but are not to be used concurrently because supportive data are currently lacking. Green and Anderson explained that despite the patients’ hemoglobin A_1c or glycemic control, there are guideline-directed therapies that should be used when CKD or cardiac complications are present to reduce the risk of CV events and progression of kidney disease.

Overcoming Barriers to Using and Adhering to Guideline-Directed Therapy

Green explained that in clinical practice, many patients with T2D, CKD, and cardiac complications are receiving metformin but not taking CV and renal protective drugs. She reminded practitioners that “these beneficial medications are recommended for patients at higher risk, irrespective of whether they need additional glucose lowering and also irrespective of whether they’re on metformin. So it doesn’t have to be metformin first.” Green explained that guideline-based therapies are often not prescribed because they represent a change in practice, are associated with new costs and adverse effects, and are not part of the current routine. However, Green said, “It’s incredibly important to spend those extra few minutes because maybe you will prevent that patient from needing dialysis for the remainder of their life; so it’s worth the time. I would encourage [clinicians] who are not prescribing, for example, the SGLT2 inhibitors on a regular basis for patients with kidney disease [to] just get started. Do it a few times. Generally, you see it all goes well. There are no major issues. You have to dip your toe in the water so that you can become comfortable with it and make it part of your standard practice.”

Cohen added that population health management approaches can be beneficial in transitioning clinical practice. For example, health care companies could identify subsets of patients who should be receiving SGLT2 inhibitors but are not. Clinical pharmacists can then use this information to make recommendations to improve patient care.

Anderson explained that the hospitalist community has been working to identify gaps in care regarding guideline-directed therapy. He reiterated that any specialty provider who identifies a gap in care should address it, whether directly or through communication with primary care clinicians, to break down silos in health care and ensure initiation and continuity of care. Nicholas noted an additional gap in sustaining guideline-directed medical therapies over time. “We observed from our [CKD] registry that patients who are on RAS inhibitors at baseline could [have adherence] as high as 70%, but within 3 months it’s declined [to] about 40%. That’s a huge gap. And similarly, if you look at patients who are starting SGLT2 inhibitors, their [therapy is] not sustained,” she said. She added that it’s critical to follow up with colleagues to ensure these medications are being refilled.

From the payer perspective, Cohen explained that adherence can be improved through disease management programs and by standardizing care and referral points. Cohen added, “It comes down to systems more than [quality] measures; having the systems in place so that irrespective of what the measure is, you can have…a collaborative infrastructure that supports meeting these measurement guidelines across the whole continuum.” Haumschild echoed that “it’s not just about chasing an individual quality measure, but it’s building that framework of success where then you naturally achieve those quality measures because you have that multidisciplinary team [and] you have that infrastructure for transitions of care.” Nevertheless, Anderson noted that the Healthcare Effectiveness Data and Information Set and MIPS quality measures do provide benefit by encouraging providers to prescribe appropriate medications. Anderson also encouraged PCPs to communicate all their findings to the nephrologist to facilitate optimal patient care, noting that “we have to set our specialists up for success when we’re referring to them.” Nicholas added that the KDIGO guidelines have recently been modified to recommend a more comprehensive approach by providing multidisciplinary care.

Unmet Needs and Future Directions in CKD Management

Higher incidence of CKD and worse outcomes have been associated with racial and ethnic minority populations, and social determinants of health (SDOH) within these communities can have a role in increasing these disparities.^9,17 Defined as the conditions in which people are born, grow, work, live, and age, SDOH can affect health by mediating access to health care and resources as well as impeding the ability to alter adverse living conditions.¹⁷ Among adults with CKD and diabetes in the United States, SDOH contribute to mortality risk in a cumulative manner, with factors such as poverty and depression being particularly detrimental.¹⁷ To address social disparities that contribute to poor outcomes for CKD, screening for SDOH should be incorporated into clinical practice to facilitate the early recognition of adverse factors.¹⁷ Furthermore, policies and programs aimed at supporting sustainable interventions for these uncovered issues are needed.¹⁷ Efforts are underway, such as recent legislation through the Inflation Reduction Act of 2022, to reduce out-of-pocket costs for patients by capping Medicare Part D beneficiary cost sharing.¹⁸ Capping costs essentially closes the coverage gap, or donut hole, whereby beneficiaries were required to pay full cost for drugs once they exceed the annual spending allowance.¹⁸

Additional barriers to optimal CKD identification and management among primary care practices include limited time and clinical support to care for numerous patients with competing medical priorities.¹² To enhance health care operations and patient care, there has been increasing focus on artificial intelligence (AI) technology utilizing EHRs.¹⁹ The comprehensive patient health data within EHRs offer extensive medical insights, which are valuable for personalized medicine, clinical decision support, and improving quality of care.¹⁹ Additionally, EHR data could potentially be used for AI-driven drug development by using clinical trial data utilization systems to exchange standard data.¹⁹

Stakeholder Insights

Nicholas reiterated several unmet needs, including early diagnosis of CKD and education on guideline-directed therapies. Nicholas also highlighted SDOH as a major barrier to optimal outcomes and discussed opportunities to bring SDOH information forward to be addressed. “We’re now beginning to focus on [SDOH] and trying to get that information from the patient into the [EHR]…[and] we’re only now beginning to understand [their] impact,” she said. Information sharing of SDOH should be promoted among providers as well as patients, who are often unaware of how adverse SDOH affect their long-term health. Examples of SDOH include transportation vulnerability, financial toxicity, and food insecurity.

Anderson explained that barriers to screening in primary care are minimal because routine screenings are typically well covered and readily available. However, providers have numerous screening procedures to implement, so the focus should be on education and developing systems to ensure the appropriate screenings are conducted. Anderson added that “from a primary care perspective, it’s more about education. It’s more about developing a system to do the right things than it is about barriers. There are very [few] barriers that I experience [when] doing proper screening for patients of any kind of disease state.” Anderson reiterated that providing incentives, reminders, and education to PCPs can lead to improved screening rates. The panel discussed using EHRs to facilitate timely screenings and follow-up care for patients, emphasizing that EHRs should include embedded SOCs and reminders to ensure that patients receive the necessary screenings. Green suggested creating order sets in EHRs that automatically identify and order overdue screenings for patients with specific conditions. Nicholas added that the CKD diagnosis should be automatically populated based on laboratory results, streamlining the diagnostic process. “I see [a no-click solution] with making the diagnosis of [CKD]. You look into the [EHR] system…and patients have CKD based on their eGFR, but they do not have a diagnosis code. We don’t need to click for that. No, it should just be there,” she said.

To limit the high costs associated with end-stage kidney disease (ESKD), Cohen explained, “it comes down to how our health care system is structured. We predominantly exist in the health care structure that treats illness as opposed to preventing illness and progression. If you can shift accountability for cost of care to a physician or a hospital organization, it changes the paradigm.” An example is building clinical decision support models for prescribing in conditions such as T2D, considering various factors and comorbidities to recommend optimal therapies. However, these investments can be costly and may require a return on investment to be feasible. Cohen concluded that redesigning payment systems and moving away from fee-for-service models will facilitate physician decision-making based on the overall budget for a patient population, ultimately leading to improved patient care. Nicholas agreed but reiterated that most patients with advanced CKD will die from CVD before reaching ESKD. Therefore, a commitment to early diagnosis and communication with patients to ensure adherence is essential to prevent suboptimal care, which leads to high mortality. Nicholas added, “It’s something that…needs to be very widespread—having that cognizance and that mentality that I need to make sure this patient does not die from heart disease by managing their [CKD].”

Cohen explained that barriers to medication utilization should be minimal because health plans often default to covering expensive drugs in the absence of sufficient evidence, which can result in increased premiums. However, Anderson, Cohen, and Haumschild agreed that even with drug coverage, there are financial barriers to medication utilization, including the Medicare donut hole and coinsurance out-of-pocket expenses, which should be ameliorated with the Inflation Reduction Act.

Cohen and Nicholas highlighted the value of utilizing extensive data sets and registries to optimize care for patients with CKD. Specifically, Nicholas suggested utilizing AI simulation modeling and machine learning to identify potentially modifiable risk factors, leading to precision medicine. Cohen recommended conducting synthetic randomized controlled trials (RCTs) using large data warehouses containing millions of patient records to provide insights that parallel those from traditional RCTs and explore questions that RCTs may not address.

Nicholas emphasized additional future considerations in CKD progression, including preventing CKD altogether by focusing on risk factors such as obesity, diabetes, and acute kidney injury. Green and Anderson discussed the tremendous strides that have been made in improving the health and outcomes of individuals with CKD, T2D, and CVD. Green emphasized that “it is astounding the therapies we have not just for glycemic lowering but for treatment of all kinds of comorbidities and…the ability to screen and hopefully intervene early in preventing the progression of CKD. But none of it makes any difference [if] it is not getting in the patient’s hands.” Nicholas reiterated that education, awareness, and addressing SDOH are crucial to optimizing treatment and adherence among patients with CKD. Cohen concluded that simplifying the health care process will ensure more patients receive the necessary therapies, explaining that “we need to shift our focus away from the responsibility of every provider doing everything right, because frankly it’s a daunting task, and build systems that will aid them through clinical decision support, through case management, [and] through population health management software platforms to really make the job easier.” •

References

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15. Cohen K, Ameli O, Chaisson CE, et al. Comparison of care quality metrics in 2-sided risk Medicare Advantage vs fee-for-service Medicare programs. JAMA Netw Open. 2022;5(12):e2246064. doi:10.1001/jamanetworkopen.2022.46064

16. Tummalapalli S, Struthers SA, White DL, et al. Optimal care for kidney health: development of a Merit-based Incentive Payment System (MIPS) value pathway. J Am Soc Nephrol. 2023;34(8):1315-1328. doi:10.1681/ASN.0000000000000163

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