Early Identification of Chronic Kidney Disease Key to Lowering Costs

Slowing progression helps to improve plan member outcomes, manage payor costs
COMMENTARY
August 23, 2021
Senior Medical Director, Accordant Health Services

More than one in seven U.S. adults — 37 million — are estimated to have chronic kidney disease (CKD).https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html Comorbidities are common; up to 85 percent of those with advanced CKD have at least one other chronic condition.https://www.medscape.org/viewarticle/736181 It is often referred to as a “silent disease” because symptoms may not appear in the early stages, allowing it to develop undetected.

In fact, up to 48 percent of people with severely reduced kidney function aren’t aware that they are suffering from kidney disease.https://www.cdc.gov/kidneydisease/basics.html Thirty-three percent of people arrive at kidney failure having had no prior management of their disease.United States Renal Data System. 2019 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2019.

When the disease does present, people may end up crashing into care, which can be both debilitating and costly. Care becomes disproportionately focused on treatment after the loss of critical kidney function. At this stage, medical management or renal replacement therapy — transplant or dialysis — is required.

Average in-center hemodialysis costs

$1K per dialysis sessionhttps://www.ncbi.nlm.nih.gov/pubmed/31081858 $180K per member per year (PMPY) overall medical costshttps://www.ncbi.nlm.nih.gov/pubmed/31081858 $26K for hospital admissions for 11 dayshttps://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day
$1K per dialysis session5
$180K per member per year (PMPY) overall medical costs6
$26K for hospital admissions for 11 days7

Earlier identification increases planned transitions

We believe it is imperative to identify members expected to progress to kidney replacement therapy earlier in their care journey. By doing so, we can lower costs for payors while we support:

Checkmark Educate members about the signs of disease progression
Checkmark Improve clinical outcomes
Checkmark Regress disease progression
Checkmark Manage comorbidities
Checkmark Avoid acute events
Checkmark Complete a choice for renal replacement therapy
Checkmark Increase planned transitions and ensure a transition plan is in place
Checkmark Incorporate caregivers into renal replacement therapy decisions
Checkmark Identify other impacts on care, including psychosocial, wellness and prevention, and social determinants of health

Our CKD care management solution can measure gaps in care and uses proprietary machine-learning models to help identify and individualize care. Built on the foundation of 20 million lives, our model identifies members based on risk of advancing to kidney failure rather than stratifying by CKD stage.

Using this approach, we can identify 105 percent more members expected to progress to kidney replacement therapy.As compared to using only a rules-based approach with limited focus on stages 4 and 5. CVS Kidney Care Analytics, 2020. Latest model performance metrics from CVS Kidney Care Analytics team. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Eligibility for the CKD program is based on the member’s predicted time to treatment instead of the disease stage.

22% increase in planned dialysis starts over baseline during a 12-month analysis Average of $60K savings per planned start of commercial memberPlanned Dialysis Start vs Unplanned Dialysis Start savings amount for a Chronic Dialysis Start looking at an 8-month window of 5 months before and 3 months following dialysis start. CVS Health Analytics, 2021. Medical Claims Data from 8/2018 – 3/2020. Planned Dialysis Start vs Unplanned Dialysis Start savings for a Chronic Dialysis Start based on an analysis of an eight-month window; five months before and three months following chronic dialysis start. Excludes COB claims and high cost outlier claims. All data sharing complies with applicable law, our information firewall and any applicable contractual limitations. Savings projections are based on CVS Health data. Actual results may vary depending on benefit plan design, member demographics, programs implemented by the plan and other factors. Client‐specific modeling available upon request.
22% increase in planned dialysis starts over baseline during a 12-month analysis
Average of $60K savings per planned start of commercial member12

Slowing disease progression through the primary nurse model

Once a member is identified, the Accordant primary nurse model provides care coordination and education. Working alongside the member’s primary doctors, Accordant nurses provide one-to-one support to optimize care and close gaps.

In one such case, a member was diagnosed with stage 4 CKD with comorbidities of type 2 diabetes mellitus with diabetic neuropathy and hypertension. Under the guidance of his nurse, the member agreed to target a specific key risk — nutrition — to prevent further progression of the CKD and to control the comorbidities.

Applying motivation behavioral techniques, the Accordant nurse was able to implement and track the member’s care plan. In addition to educating the member about nutrition, the nurse offered caregiver support and help with care planning, including steps toward preparation for renal replacement therapy when necessary.

During 18 months in the Accordant program, the member reduced proteins, eliminated many processed foods and began eating smaller meals with more vegetables. At the same time, the nurse worked with the member to implement strategies to target the comorbidities, encouraging the member to walk half a mile each day — an increase from a mainly sedentary life — and adding small free weights to the day’s walk. Together these steps enabled the member to maintain stage 4 CKD without the disease progressing.

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COMMENTARY
August 23, 2021
Senior Medical Director, Accordant Health Services