Transforming Kidney Care: Policy, Risk Stratification, and Collaborative Models

Am J Manag Care. 2024;30(Spec. No. 13):SP1041-SP1043

On September 26, 2024, speakers gathered in Park City, Utah, to discuss the state of kidney care and how risk stratification, public policy, and interdisciplinary communication can enhance patient outcomes. Hosted in partnership with Intermountain Health, the Institute for Value-Based Medicine event “Optimizing Kidney Health: Advancing Proactive Care Models” highlighted perspectives that advocated for new outlooks in kidney care. Presenters focused on the need for early detection and risk assessments, cost-effective care, health policy reform, and the interconnectedness of cardiometabolic and cardiorenal syndromes.

“Health policy is always full of very simple-sounding problems and solutions, and when you dig into it, you find that this is a policy area that is full of extraordinarily complicated chaos,” began Miriam Godwin, CMMI, director of health policy at the National Kidney Foundation. Godwin spotlighted how quality of care is being negatively affected by high and rising costs of health care spending, lack of transparency, and structural insufficiencies. Transforming public policy and implementing value-based care models will require dedication, the right value judgments, and, most of all, patience, she said.

Despite “spending an astronomical amount of money,” Godwin pointed out, high health care costs have not equated to better patient outcomes.¹ Health care spending concerns everyone, she said, and Medicare spending impacts wages, taxes, and insurance. Costs also create barriers to health care innovation, Godwin added, because “there’s no pathway to a breakthrough that does not require funding along the way.”

According to Godwin, regulatory policy offers opportunities to address these challenges. CMS aims to transition all beneficiaries, including those on Medicare Advantage, into an accountable care relationship by 2030, with models supporting organ transplant access, home dialysis, and patient- and nephrologist-centered care. These steps are crucial as gaps in chronic kidney disease (CKD) management, such as the need for earlier intervention and screening efforts, become more evident.

“To address CKD is to invest not only in early intervention and management but also in the hope of a longer, healthier life for those at risk. It’s a journey that requires both clinical insight and compassionate policy,” Godwin said.

Population health strategies for CKD need more support and visibility from policy makers, according to Godwin. Although these frameworks already exist, very short evaluation timelines make it challenging to prove they are worth the investment. Quality measures and risk stratification efforts, such as those employed by the National Kidney Foundation’s CKDintercept program, are crucial for improving CKD care and diagnosis. Furthermore, incentives remain necessary to facilitate better connections between metabolic syndrome care, CKD care, and primary care—especially in the realm of Medicare and other health plans.

As efforts to create pathways for CKD management gain traction, the need to prioritize CKD screening and risk stratification will increase, Godwin reiterated. Meaningful change, however, is a “long game” that requires generational commitments, a balance of competing value judgments, and the patience to work toward impactful progress. Although advocacy and policy shifts take time, incremental victories—such as improving access to home dialysis or transplants—are vital for changing the culture around health issues and advancing patient care. Equally important is keeping patients’ stories in mind and adding a “human touch” to these issues, she said.

Navdeep Tangri, MD, PhD, FRCP, attending physician and associate professor at the University of Manitoba in Winnipeg, furthered this discussion by exploring the limitations of CKD care models. “We live in an era where CKD care is largely based on eGFR [estimated glomerular filtration rate], and that’s not really the right model,” he said. “When you create care based on eGFR alone, you do not deliver personalized treatment. High-risk patients get undertreated and crash into dialysis or kidney failure, and low-risk patients may be overtreated and get unnecessary [adverse] effects.”

Risk stratification approaches can drastically alter CKD care by promoting early identification and targeted interventions for high-risk patients. Diagnosing these patients sooner would have a profound impact on rates of disease progression and frequency of hospitalizations and could prevent unnecessary treatments for lower-risk patients.

Tangri highlighted the new Klinrisk test that he and colleagues developed as “a model for everyone” that builds off their previous Kidney Failure Risk Equation. This upgrade estimates CKD progression in earlier stages, addressing a glaring need for patients with CKD stages 1 to 5 and those at risk (including those with diabetes and hypertension). Furthermore, this model works to combat unnecessary costs and relieve administrative burden by leaning into routine patient demographic and laboratory data (ie, age, race, eGFR, urine albumin to creatinine ratio) to predict a composite 40% decline in eGFR—an end point validated by the FDA—while avoiding biomarker assays and bypassing the need to access electronic health records. Data on 2- and 5-year outcomes demonstrated the model’s extreme accuracy at detecting progressive events at a rate of 87% and 77%, respectively.²

“In high-risk patients, CKD is the driver of costs. So naturally, CKD-related interventions can drive those costs. Those are actually the modifiable costs,” Tangri posited, explaining how risk stratification serves not only to identify high-risk patients but also to intervene less on lower-risk individuals.

High-risk patients are spread out across various CKD stages, which can lead to suboptimal care, he said. “If you look just at stage, you will miss the majority of high-risk patients who are in stage 1 to 3a, and you will overtreat or perhaps provide a whole bunch of education, care management, really costly resources, time, and energy to about two-thirds of people in stage 3 to 4 who don’t need that care today,” Tangri said.³

Tangri noted that staging is just a first step and that risk stratification must follow because “the earlier we start, the greater impact we’ll have for an individual patient over a lifetime.” He concluded by emphasizing that dialysis, hospitalizations, and unnecessary care can be prevented when therapy begins sooner, rather than later.

Viet Le, PA-C, associate professor of research at Intermountain Health, drew attention to another avenue for improving outcomes in patients with cardiorenal or cardiometabolic diseases such as CKD: interdisciplinary collaboration. He spoke about the interconnectedness of cardiovascular and renal medicine, arguing that a more holistic approach, with concerted efforts from cardiologists and nephrologists, opens a path to better treat patients with cardio-kidney-metabolic (CKM) diseases. After all, diabetes management often serves a broader goal of protecting both the heart and kidneys.

Cardiovascular disease affects 50% of patients with CKD stages 4 and 5 and contributes to 40% to 50% of deaths in this population.⁴ “So in the center of it all is the heart,” Le stated, noting the importance of CKM health in patients with type 2 diabetes, liver disease, and more. He mentioned the difficulty of implementing CKM care models because of notions about patients “belonging” to the cardiology department or the nephrology department. “No one owns the patient,” Le declared.

He presented a complicated case of a patient with multiple comorbidities to demonstrate the importance of a CKM approach to mitigate how quickly the number of interventions and monthly costs compound. “Why am I, in preventive cardiology, thinking about all the pieces when it should be a group of us with nephrology involved, with our endocrinology partners?” he asked.

Le concluded by advocating for proactive interventions in earlier CKD stages to prevent severe complications and reduce financial strain for patients and health systems alike. His final message called for a shift toward preventive therapy to manage upstream risks to ultimately lower mortality and morbidity among patients with CKD.

“Do we really want to wait for people at the bottom of a cliff with an ambulance and try to pick up the pieces if they survive? Or do you want to put the fence up at the top of the hill and deploy preventive medicines and preventive therapy?… Let’s build this clinic and see where it takes us,” Le said encouragingly to the audience.

Author Information: Mr Munz is an employee of MJH Life Sciences, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. Gunja MZ, Gumas ED, Williams II RD. U.S. health care from a global perspective, 2022: accelerating spending, worsening outcomes. The Commonwealth Fund. January 31, 2023. Accessed October 28, 2024. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022
2. Ferguson T, Ravani P, Sood MM, et al. Development and external validation of a machine learning model for progression of CKD. Kidney Int Rep. 2022;7(8):1772-1781. doi:10.1016/j.ekir.2022.05.004
3. Tangri N, Ferguson TW, Bamforth RJ, et al. External validation of the Klinrisk model in U.S. commercial, Medicare Advantage, and Medicaid populations. J Am Soc Nephrol. 2023;34(suppl 11):71. doi:10.1681/ASN.20233411S171a
4. Jankowski J, Floege J, Fliser D, Böhm M, Marx N. Cardiovascular disease in chronic kidney disease: pathophysiological insights and therapeutic options. Circulation. 2021;143(11):1157-1172. doi:10.1161/CIRCULATIONAHA.120.050686