Payer-provider collaboration in ESRD care

When payers and providers unite against this pervasive disease, they generate a greater wealth of potentially life-saving data. A provider’s cache of electronic health records (EHRs) holds the key to identifying early signs of kidney disease and those patients at risk of developing it. And a payer’s capacity for data analysis can turn that key.

By combing through EHRs to find clusters of kidney-related symptoms — members who’ve complained of nausea, fatigue and decreased urination, for example⁵ — payers can trigger providers to look more deeply into the possibility of kidney disease, noting the additional presence of any comorbid conditions and SDOH that may contribute. This increased focus can be used to alert the patient, as well, urging them to keep a closer eye on their symptoms. The upshot? More CKD patients will be identified sooner — and more may be spared from ever reaching the end stages of the disease.

Roughly 560,000 Americans receive dialysis each year at an average cost of $92,000.³ What’s more, the average patient can expect to continue these time-intensive treatments for anywhere between 5 and 10 years, though some patients continue for much longer. It’s no wonder, then, that costs run rampant: Medicare spending for patients with CKD age 66 or older is more than $70 billion a year, or nearly a fourth of the program’s overall spend. Medicare spending for those with ESRD adds another $49 billion each year.³

Despite its expense, in-clinic dialysis doesn’t deliver the best results. At-home dialysis, research shows, offers the same effectiveness with greater quality of life and far fewer side effects. Patients conducting their dialysis at home report higher energy levels, better sleep and a more robust appetite, without the scheduling hindrances that occur with in-clinic treatments.⁶ In addition, in-home dialysis is much more cost-effective. One study conducted by the Center for Medicare & Medicaid Services (CMS) found that roughly $23.5 million could be saved over five and a half years if just a third of its ESRD patients switched from in-clinic to at-home dialysis.²

When payers and providers work together, increasing member usage of at-home dialysis becomes a smart path to both better patient outcomes and reduced costs. Specifically, payers are well-positioned to help members address barriers to at-home dialysis, which a 2020 study identified as unstable living conditions, insufficient space, poor health literacy and limited family support.⁷ These circumstances can be mitigated through payer-funded managed care programs that send kidney-trained nurses to people’s homes to offer support, guidance, care coordination and health education.

Obtaining prior authorization from a health plan can sometimes take members multiple days, a slowdown with potentially dire consequences. According to a 2021 survey conducted by the American Medical Association, 34% of physicians said that waiting for prior authorization had caused a “serious adverse event,” including death or permanent damage. Further, 82% of physicians surveyed said that prior authorization can lead to a patient abandoning their recommended course of treatment, and 93% agreed that it delays care.⁸

Payers and providers can eliminate this roadblock by pre-negotiating authorizations in cases that meet agreed-upon criteria. Payers can determine these conditions in advance, basing them on case complexity or urgency of need, for example, and shift their policies to automatically approve cases that fall within these parameters. This speeds the process for both providers and patients — and avoids more needless downturns in patient health.

CKD and ESRD continue to be diseases marked by tremendous health disparities.⁹ Communities of color are diagnosed more frequently, use dialysis more, are less likely to obtain a transplant — or even a transplant evaluation — and are more likely to experience kidney failure than their white counterparts.^10,11 And though 58% of providers polled by the Institute for Healthcare Improvement believe that achieving health equity is of great importance, many also feel that they don’t have the resources necessary to do so.¹² Specifically, 38% of providers say that inconsistent data collection hinders their equity efforts, and 26% say they lack the know-how to begin tackling these problems.¹²

These challenges represent a unique opportunity for payers. By partnering with providers on data collection and analysis, payers can help to identify key risk factors for underserved communities and proactively move to address them. On a broader scale, payers can offer providers comprehensive guidance around health equity via educational seminars, webinars and other content resources.

Providers in the IHI survey also noted structural changes they’d like to see from payers to improve equity, including changes to reimbursement policies (30% of those surveyed) and more accessible treatment options to better reach vulnerable populations, such as telehealth services (20% of respondents).¹²

The upsides of preemptive and early kidney transplants speak for themselves. The National Kidney Foundation reports that preemptive transplants (those that occur before dialysis) and early transplants (which occur after only a brief time on dialysis) offer patients greater quality of life, fewer lifestyle restrictions, lower treatment costs for both patient and plan, and fewer organ rejections.¹³ Yet despite this, only 2.5% of kidney transplants in the nation are performed before starting dialysis.¹⁴

If payers can better educate providers on the profound benefits of early transplants — and encourage them to have the transplant conversation with members sooner in their treatment journey — they stand to boost patient outcomes and lower dialysis costs. And while no one can increase the number of available kidneys (currently, 92,000 people are waiting for a transplant, according to the American Kidney Fund),¹⁵ these forms of advocacy can help ESRD patients get on the waitlist much sooner. Payers might consider adding a layer of assistance between ESRD patients and their healthcare providers, such as a care coordinator trained to help patients navigate the transplant process.

Effectively managing CKD and ESRD presents complex challenges. But by uniting payers’ and providers’ efforts to improve diagnosis and treatment, the healthcare industry can deliver better, more efficient care to millions of patients.