Episode 31: Improving Patient Outcomes and Reducing Total Costs with Dr. Terry Ketchersid and David Pollack

Comprehensive Kidney Care Contracting, a new value based care initiative in 2022 by the Centers for Medicare and Medicaid Services, aims to improve outcomes and reduce costs by assisting patients with kidney disease prior to the need for renal replacement therapy. Dr. Terry Ketchersid, Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America, and the co-CMO for InterWell Health, and David Pollack, President of the Integrated Care Group, join to discuss the new program.

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DISCLAIMER: The statements contained in this podcast are solely those of the speakers and do not necessarily reflect the views or policies of CMS. The interview subjects assume responsibility for the accuracy and completeness of the information contained in this podcast.

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Brad Puffer: Welcome everyone to this episode of Field Notes. I’m Brad Puffer on the Medical Office Communications team at Fresenius Medical Care North America and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. The Innovation Center with the Centers for Medicare and Medicaid Services has an important new value based care initiative in 2022 for patients with late-stage kidney disease, called Kidney Care Choices. Now, this is aligned with our company's leading efforts to assist more patients with kidney disease prior to the need for renal replacement therapy. And it includes strong financial incentives for providers to improve outcomes and reduce costs for patients with ESRD and advanced CKD.  Fresenius Medical Care North America’s value based care division is now the leading participant in these new contracts with the government. Here to explain more about the program, what it means for our patients, and why it matters for our physicians is Dr. Terry Ketchersid, Chief Medical Officer for our Integrated Care Group and co-CMO for InterWell Health, and David Pollack, President of the company’s Integrated Care Group.

Doctor Ketchersid, David, welcome to Field Notes. 

Dr. Ketchersid: Thank you. 

David Pollack: Hi Brad, thanks for having Terry and I on today. 

Brad Puffer: Dr. Ketchersid, let’s start at the top. I just would love to get a little background on what the Kidney Care Choices model is all about. What's the hope of the government program? 

Dr. Ketchersid: So, Kidney Care Choices is basically the new set of value based care programs coming out of the Innovation Center that are focused on patients with advanced renal disease. Within KCC, Kidney Care Choices, there's an option called the Comprehensive Kidney Care Contracting or CKCC option. Many people have called this the next version of the ESCO, although it has substantial improvements over what the ESCO brought. These are two-sided, total cost or clear risk arrangements for Medicare beneficiaries with both end stage renal disease and stage four and stage five CKD. Some of those improvements include the addition of the stage four and five patients, as well as substantially more transparency than we were exposed to in the ESCO program. So, the hope from the perspective of the government? I think at the end of the day, what they're trying to do is to continue to answer the following question: Are patients with advanced renal disease different enough that they need a unique payment program? What's being tested is, can outcomes improve, or at least remain the same, while costs go down for this patient population? 

Brad Puffer: Great, thank you Dr. Ketchersid. Turning to you David, this all seems very aligned with what Fresenius Medical Care and your value based care team has already been doing. Dr. Ketchersid mentioned the ESCO model. We've been involved in government models for a long time. We also contract with private payers right now, managing late stage kidney disease and seeing some great results. Does this experience make a difference as we enter into these new agreements? 

David Pollack: Without a doubt, experience matters in these programs and quite honestly, it's just a fact that we have far more experience than anybody else out there. And if I could just put a few numbers to it: when I look at our experience over the last five or six years, we've managed over $20 billion of medical costs in that time. We've touched over 500,000 individual people. When we look at these new models and where we are today, we're looking at about 100,000 ESRD and CKD patients in our value based care programs.  So, we know what works and quite honestly, and maybe just as importantly, we know what doesn't work. And we've got in place today the internal infrastructure and leadership in place to effectively operate these programs. So, this experience does put us in the perfect position to begin the new models and continue to work with the payers that we work with today and new payers going out into the future. 

Brad Puffer: And David, I understand as part of this, we're forming joint ventures with nephrologists to help deliver better patient outcomes and those results in these models. Can you talk about that partnership with nephrologists, and how confident you are that we can deliver the results the government is looking for?

David Pollack: Yeah, certainly. I think our partnerships with nephrologists are really a critical part of performance in these programs. We have formed multiple levels of partnerships. So first, as you as you mentioned, we've formed a 50/50 joint venture with nephrologists. That company is named InterWell Health; Terry is a co-CMO of that organization. And that network of nephrologists now includes over 1500 nephrologists and over 1000 of them are actual investors in the joint venture. It's by far the largest network in the country. And then secondly, within the Kidney Care Choices model, we’ve formed partnerships with 73 participating practices, and we've developed individual care models that are unique to each practice. It really depends on the needs of each practice, and so the partnerships are really critical. They leave me with zero doubt we're going to be successful in these programs. 

Brad Puffer: You know, David just talked about the scale and the number of partnerships, the number of nephrologists and patients that we have involved in these programs. Why does scale matter? 

Dr. Ketchersid: Well scale is huge. Not to be funny about it, Brad, but scale matters a lot. As David highlighted, the fact that we've been at this for so long, and we've had the opportunity to try a number of things… you know, everything we try doesn't work. I mean, we've made mistakes, mistakes by the way that others are about to make, and we've learned from those mistakes and the program has evolved. In fact, important to that conversation, if you think about it, machine learning and artificial intelligence – those are almost throwaway words, almost table stakes now. But everybody uses them. The difference is when we use them, we know which ones work.  We have years of experience. It's one thing to set out to use a specific, predictive model; it's another thing to have a couple of years of experience under your belt to know which one works and which one doesn't work. Scale is one of the most important aspects. Scale and experience. 

Brad Puffer: And Dr. Ketchersid, we have announced recently that one of the programs that we're using to help manage these patients, the KidneyCare:365 CKD health program received accreditation by the National Committee for Quality Assurance. This is a leading nonprofit organization with really high standards for evaluating population health programs. Can you tell us a little bit more about what KidneyCare:365 is all about and how does that help us in managing patients in value based care programs? 

Dr. Ketchersid: Let me start with the NCQA accreditation. This is an extremely important milestone in the evolution of our company. In fact, very, very few of the enterprises that are attempting to do value based care work in the renal space have actually achieved this outstanding accreditation. To be clear, this is not simple window dressing. This requires months of scrutiny. Our solution was accredited for the maximum timeframe: a three-year accreditation. So, what did they actually accredit? The KidneyCare:365 is a robust, end-to-end care coordination solution for patients with advanced renal disease. If we had a number of hours, we could explain the substantial breadth of the program and how it works closely with the patient's local care team to help coordinate this complex journey that they're on with respect to advanced renal disease. 

Brad Puffer: So, Dr. Ketchersid, maybe you can expand a little bit more on just how this program works and some of the great results that we've seen today. 

Dr. Ketchersid: I'd be happy to, Brad. We're extremely proud of the results that we're seeing. We see engagement rates for the CKD population involved with KidneyCare:365, north of 50%. Also, when you look at the patients, the CKD patients that are involved in KidneyCare:365, well over half of them are engaged with a renal dietitian. Almost 30% of them have a relationship with a social worker. And importantly, we spend a lot of time talking to patients in collaboration with their local care teams about modality selection. And our most recent statistics suggest that 45% of those patients that have made a choice have selected home dialysis as a modality should they progress to end stage renal disease. Very impressive results, Brad, related to all the work that's been put into the development of this application. 

Brad Puffer: David, back to you. You know, in addition to the government models that we discussed at the top of our discussion, we're obviously seeing a lot of interest from major insurance companies across the country partnering with us to manage people living with kidney disease. Has it surprised you just how fast these programs are growing?

David Pollack: Yeah, so I don't know if surprised is the right word. Just in my background, I've spent 25 years leading managed care companies before I came over to Fresenius. And then, in a good part of that time at those companies, they would regularly look at the population and would identify individuals with ESRD and chronic kidney disease as populations where those managed care companies needed some help. But there was never the right partner out there, so that's really the market need that we are filling right now. It's very specialized; it requires really dedicated resources and deep partnerships in order to provide the right outcomes for the payor. So, if you build it, they will come, and I think with the right outcomes these programs will continue to grow extremely fast. 

Brad Puffer: And Dr. Ketchersid, you had mentioned home dialysis, and I'd mentioned that that's a huge company goal. Why do these programs, value based care programs, help us accelerate the growth of home therapies?

Dr. Ketchersid: Clearly, we've been pushing hard on home dialysis. It's clearly the right thing to do for patients. And these new payment models have created financial incentives that are aligned with that goal. If you look at the voluntary model that we've just discussed, there's a substantial incentive with respect to optimal starts. Optimal starts, meaning starting dialysis without a central venous catheter, will certainly continue to increase the focus on peritoneal dialysis, home hemodialysis, with a fistula or graft.  The mandatory model, which is also under the jurisdiction of CMMI, so called ESRD treatment choices model, also creates financial incentives that reward the same thing. When we're out talking with our nephrology partners, one of the things we highlight is that both of these programs are creating financial rewards to continue to do the right thing. Move people to home dialysis and increase the rate of transplantation. 

Brad Puffer: And as we talk about transplantation, obviously a huge goal is to get a preemptive transplant or increased transplant referrals. There's a challenge there though, right? We have a limited number of transplants even available. How are we addressing that? 

Dr. Ketchersid: Yes, everybody listening to Field Notes recognizes that transplant is by far the best treatment for end stage renal disease. Certainly, for patients that are clinically suited to receive a transplant. And yet we have a substantial supply and demand problem. On any given day, there are roughly 100,000 patients sitting on somebody's transplant waiting list. And yet, in our best years, we managed to transplant 20,000 kidneys during the year. Now these programs will help. They won't solve the supply issue. But I do think, Brad, that there's a chance that they will increase interest in living/related donation. And these models aren't the only thing happening in this space. They're not happening in isolation. There's a substantial effort to change the way that organ procurement organizations operate. And I think that in and of itself will also lend some relief to the supply issue that exists today. 

Brad Puffer: David, turning back to you, as we see these new government models get underway, and especially the ones we're talking here that are launched in 2022, do you think these models will be here to stay? Will there be new models coming down the line to replace them or, what's the future of these value based care initiatives? 

David Pollack: Well, certainly, value based care is here to stay. You know, will this model be tweaked over time? I think it probably will, so I don't know if this will be the final model that eventually stays in place. But what I certainly can say is that payments to both dialysis providers and nephrologists will continue to change based on value based care principles and the concept of what's in this model. So, Terry talked about optimal starts and other quality metrics we have in this model. We have patient reported outcome measures like, patient activation tools and measures. Those are part of these models, and I think a look at total cost of care. All of these things will be part of a formula that determines final provider compensation, and so again, without a doubt there will be a long-term government model that uses a lot of these value based care concepts.

Brad Puffer: Dr. Ketchersid, would love your take on kind of the future of value based care and these government models as well, whether it's private payors or the government. Will this ultimately be the dominant way that we manage patients with kidney disease? 

Dr. Ketchersid: Let me respond in this way: the Innovation Center at CMMI has really been at the forefront for driving value based care programs. Many of the folks listening probably don't recognize that the Innovation Center actually was born in the Affordable Care Act. It has over a decade of experience under its belt and just a couple of months ago, the Innovation Center published a white paper that described its strategy for the future, i.e., what to expect in the next decade. 

And pertinent to your question, Brad, one of the things that was highlighted in that white paper, was the fact that CMMI and CMS expect that by the year 2030, every single Medicare beneficiary will be involved in value based care. Not just those with renal disease, but every beneficiary. To David's point, value based care is here to stay. The train has not only left the station, but it is well down the tracks. 

Brad Puffer: Well that makes it very clear. If the government is that invested in this shift for the vast majority of our patients, we know where the rest of the payors will follow. Finally, turning to you, David, why are you feeling optimistic about our company's role to accelerate this change to value based care? You know, we know there's smaller startups out there, other companies trying to innovate and offer solutions with the same goal. How do you see us staying ahead with our offerings?

David Pollack: Yeah, so, Brad, thanks for using optimistic. It's actually one of my favorite words. And I certainly can tell you that as an organization we have wide buy in for the shift from volume to value. It's across the entire organization and that's really what it takes to be successful. I talked about our experience already. I talked about our partnerships with nephrologists. Those are the two things that really do set us apart right now. But as I think about it, I think of one other thing that comes to mind, and that's our long-term relationships with the nephrologists. So, not just our relationships today, but it's how we're aligned with them for success in all aspects of their practice.  We do, you mentioned some startups - we're not looking to sell like those startups might be. We're not looking to sell our value based care organization to the highest bidder. We're really in it for the long term. We want to make sure we have a sustainable model that serves the long-term interest of the practice. So really, we're able to win today and we'll keep us ahead in the future, based on our experience and providing the best outcomes, and then we have our relationships intact and our alignment to the future success of our practices. Those are the things that are going to keep us at the forefront leading this industry.

Brad Puffer: Well David, Dr. Ketchersid, it’s been a really fascinating conversation. There's so much to dig into here and it's going to be a really exciting year as these new government models launch. Thank you for joining us. And to our audience, thank you for joining us. Don't forget, you can find Field Notes on the Apple Store or Google Play or right here at FMCNA.com, where you can also find our Annual Medical Report and other featured articles. If you have any questions about the COVID-19 vaccines, please contact your primary care physician or care delivery team.  And please, if you're not already vaccinated, protect yourself and your loved ones by getting vaccinated today. Until next time, I'm Brad Puffer and you've been listening to Field Notes by Fresenius Medical Care. Take care everyone.