ADC 2016 v11 - Annual Dialysis...

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Allen R. Nissenson, MD, FACPChief Medical Officer, DaVita

Emeritus Professor of Medicine, David Geffen School of Medicine at UCLA

Kidney Careof the Future

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Abraham Lincoln

The best way to predict your future is to create it.

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What Is The Future Of Health Care?

“All signs point to a retail market.”- Health Care Advisory Board

“The combination of economic and technological changes is creating much more of a empowered, informed consumer market.”

- McKinsey & Co.

“Multiple, intersecting pressures will drive the transformation of health care delivery and financing from volume- to value-based payments over the next decade.”

- American Hospital Association

“In 2020, informed and demanding patients are now partners in their own healthcare….Health data is pervasive – requiring new tools and provider models.”

- Deloitte

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Trends in Vertical Integration

Companies from other

segments are becoming providers

http://www.healthleadersmedia.com/content/HEP-295415/1-in-5-Health-Systems-to-Become-payors-by-2018##

Payers are becoming providers

Providers are becoming

payers

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Number of Hospitals in Health Systems,

2002 – 2012

Hos

pita

ls

2,400

2,500

2,600

2,700

2,800

2,900

3,000

3,100

3,200

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Avalere Health analysis of American Hospital Association Annual Survey data, 2012, for community hospitals.

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Why ESRD Matters

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Why Renal Care Is Important

Other Medicare

Other Medicare

1USRDS 2011 2~375K ESRD + ~300K Stage 4 Chronic Kidney Disease

ESRD +Late Stage CKD

~$30Bper year

~1.5%OF PATIENTS1,2

~10%OF COSTS

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Total Medicare Dollars Spent on ESRDBy type of service

2014 USRDS ESRD Database. Total Medicare costs from claims data; includes all Medicare as primary payer claims as well as amounts paid by Medicare as secondary payer.

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• Consolidate our fragmented delivery system – Dialysis facility – Nephrology practice – Hospital systems

Key Issues: Dialysis Providers

Dialysis 20%

Out- patient costs 34%

Part D meds 6%

Hospital- izations

39%

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10

Filled and Unfilled NRMPNephrology Fellow Programs

0

38

75

113

150

2010 2011 2012 2013 2014

64

34242415

81114118122127

Filled Unfilled

Source: NRMP

Num

ber o

f Pro

gram

s

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• Clinics

• NPs / PAs

• Patient outcomes

• Care of hospitalized patients

Future Role of Nephrologists =Oversight of. . .

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• Improving outcomes in dialysis

• New approaches needed

• Delivery systems of the future

• Reimbursement systems of the future

Presentation Outline

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What Matters Most

Measures of Effectiveness

Complex Programs

The Fundamentals

Clinical Quality PyramidNissenson, Allen R. "Improving Outcomes for ESRD Patients: Shifting the Quality Paradigm." CJASN 2014.

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14

16

19

21

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96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12

22.517.1

Death Rate (Prevalent Dialysis Patients)

Dea

th R

ate

Per 1

00 P

atie

nt-Y

ears

Collins, ASN, Peer (2015); http://www.peerkidney.org/

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First-Year Hospital Admission Rates (Incident Dialysis Patients)

1.30

1.65

2.00

2.35

2.70

99 00 01 02 03 04 05 06 07 08 09 10 11 12Adm

issi

on R

ates

Per

Pat

ient

-Yea

r

YearCollins, ASN, Peer (2015); http://www.peerkidney.org/

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1.60

1.78

1.95

2.13

2.30

99 00 01 02 03 04 05 06 07 08 09 10 11 12

Hospital Admission Rates(Prevalent Dialysis Patients)

Adm

issi

on R

ates

Per

Pat

ient

-Yea

r


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30-Day Readmission Rates Among Live Discharges (Chronic Dialysis Patients)

30.0

31.0

32.0

33.0

34.0

35.0

1996 1998 2000 2002 2004 2006 2008 2010 2012For 1996-2011, 30-day readmission rate was calculated for live discharge Jan 1- Dec 31; For 2012, 30-day readmission rate was calculated for live discharge Jan 1 - June 30, 2012


30-D

ay R

eadm

issi

on R

ate

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The Triple Aims

of Health Care

Improve

experience of care

Impr

ove

healt

h

of p

opul

atio

n

Reduce health care costsDonald M. Berwick, Thomas W. Nolan, and John Whittington. “The Triple Aim: Care, Health, and Cost,” Health Affairs, Vol. 27 No. 3 (May, 2008): 759-769

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MarketEvolution

Regulators

Payors

ConsumersCollaboration

Technology

“Forcing” providers to deliver high quality careat a lower cost with high patient experience

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Risk is shifting to the natural owner

General Population

Health

PCPs/ Specialists

Episodic

Scale/Skill Providers

Chronic

Scale/Skill Providers

Catastrophic

Payors

“Lifestyle” conditions

The Consumer

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Providers must be able to:• Allocate resources to deliver population-level care in area of

core competency

• Leverage economies of scope and scale to allow these same resources to fund research

• Develop and implement key programs to furtherimprove outcomes

To Achieve the Triple Aim. . .

Innovation in the health care model is required

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Innovation in the Delivery Model

• Provider-centric

• Volume driven

• Quality given “attention”

• No focus on inefficiency

• Lack of alignment

• Safety??

• Patient-centric

• Quality driven

• Utilization focused

• Collaboration focus

• Safety focus

• Value-based arrangements

• Bigger bundles

PAST FUTURE

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What Matters Most

Measures of Effectiveness

Complex Programs

The Fundamentals

Clinical Quality PyramidNissenson, Allen R. "Improving Outcomes for ESRD Patients: Shifting the Quality Paradigm." CJASN 2014.

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2016 Focus

1) Mortality

2) Hospitalization

3) Patient experience

4) Physician experience

5) Publicly-reported data

6) “Upstream”- mid/late CKD

7) Triple Aim

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Calendar Year (Payment Year)

2015 (2017)

2016 (2018)

2017 (2019)

Performance Metrics

• Weight: 75% •• AVF/CVC (16%) • Kt/V (16%) • SIR (16%) • Ca (11%) • SRR (16%)

• Weight: 90% •• AVF/CVC (18%) • Kt/V (18%) • SIR (20%) • Ca (7%) • SRR (10%) • STrR (7%) • CAHPS x2 * (20%)

• Weight: 90% •• AVF/CVC (18%) • Kt/V (18%) • SIR (20%) • Ca (7%) • SRR (10%) • STrR (7%) • CAHPS x2 * (20%)

Reporting Metrics • Weight: 25% •• CAHPS x2 • Phos • Anemia

• Weight: 10% •• Phos • Anemia • Dep Screening • Pain Assmt • HCP Flu Vacc

• Weight: 10% •• Phos • Anemia • Dep Screening • Pain Assmt • HCP Flu Vacc

TPS • 60 • 49 • TBD

QIP

28 *SRR is currently reported on Dialysis Facility Compare, but not part of Five-Star

Five-Star

Calendar Year (Publish Date)

2015 Performance (Oct 2016)



Current Metrics

• AVF/CVC • Kt/V • Ca • SMR • SHR • STrR



Probable New Metrics

• SRR •• SRR* • CAHPS • SIR • Pedi Kt/V

• SRR* • CAHPS • SIR • Pedi Kt/V • UFR • Others?

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Most Important Measures When Evaluating The Overall Quality of the Facility

Percent of responsesTotal

(n=653)

DPC Members (n=394)

DPC Non-Members

(n=259)

Dialysis Center Staff Respect/Listening 58 59 56

Physical Comfort during Dialysis 42 41 42

Kt/V Dialysis Adequacy 41 43 38

Dialysis Patient Education 40 40 42

Healthcare-Acquired Infections 30 28 32

Anemia Management 29 32* 25

Patient Mortality and Hospitalizations 26 29* 22

Quality of Life – Cramping 25 21 30*

Healthy Days at Home 25 25 24

DPC Survey

*Statistical significance at the 90% level

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DaVita Home Dialysis System

Remote Monitoring

Risk Model

Health Management

Smart Phone App

Physician Partners

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Manage the Costly CKD to ESRD Transition

Cos

t $ P

PPM

0

10,000

20,000

30,000

40,000

-6 -5 -4 -3 -2 -1 1 2 3 4 5 6

Average PPPM Cost Through Transition to Dialysis

CKD IV / V ESRD

Months on Pre- and Post-Initiation of Dialysis

Delay CKD Progression

Transition to Dialysis

(>30% mortality)Prepare for Dialysis (40% crash)

Manage Hospitalizations (58% avoidable,

36% readmit rate)

For Commercial member; based on MarketScan data, from 2010 USRDS ADR, Volume 1, Page 137. MarketScan is a commercial claims dataset comprised of 10.5 million covered lives that USRDS uses as a benchmark for CKD utilization.

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• Top quartile to top 1% of health care costs

• Average of eight comorbidities – CV disease – 50% end-stage CV disease, CHF or CKD

• 20% of spending post hospitalization

• Significant depression and bipolar disease

Most Vulnerable Medicare Patients

Powers, Brian W., and Sreekanth K. Chaguturu. “ACOs And High-Cost Patients". NEJM 374.3 (2016): 203-205.

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• Group of doctors / hospital system paid a fixed amount for all services for enrollees

• Providers accept the risk

• Effective and predictable

• Opposite end of payment spectrum from FFS – Many other models seen as “stepping stones” from FFS

to capitation

Capitation Overview

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• Pay more than Medicare rate if quality metrics are met

• Pay if specific quality metrics are achieved – Admission rates – Catheter rates – Readmission rates

Capitation: Inclusion of Quality Measures Mitigates Any Temptation to “Skimp”

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• Medicare “Special Needs Plan”

• Integrated care model for ESRD patients(and other select chronic diseases)

• Dialysis patients cannot newly enroll in MA plans, but they can enroll in an ESRD SNP

• Risk-adjusted global capitated payment from CMS; health plan and provider share in surplus after medical expenditures

SNP Overview

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• Los Angeles-Orange County

• Launched in 2014

• Partnership between… – DaVita VillageHealth – HealthCare Partners – SCAN health plan

• Exemplary clinical results to- date (e.g., hospitalization rate, CVC rate)

SNP Example

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Full-Risk Example: Achieving the Triple Aim in ESRD C-SNP

Better than the Medicare fee-for-service sample.

15% per year.$8,000

92%Satisfaction rating in Medicare’s CAHPS 2013 survey.

Non-dialysis cost savings:

Nearly

Per member per year savings:

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ESCO Entity Structure

Each ESCO will have a Governing Body with final decision authority to execute functions of ESCO

ESCO PARTICIPANTS

Dialysisfacilities

Nephrology group(s)

OPTIONAL: Hospitals, MSGs,other providers

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ESCO Participant Framework

Hospitalization Management

ESCO Service Areas

Medication Management

Fluid Management

Diabetes Management

• ESRD patients receive treatment in the clinic3x / week 4−5 hrs / treatment (12−15 hrs /week)

• The core capabilities of the ESCO are driven by care coordination in the dialysis center

• Focus on the interventions that result in the highest quality and fewest complicationsDialysis Clinic

Patient Care Team

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26 ESCO Quality Performance MeasuresMeasure TypeDomain: Patient Safety ESCO Standardized Mortality Ratio OutcomeDocumentation of Current Medications in the Medical Record ProcessBloodstream Infection in Hemodialysis Outpatients OutcomeFalls: Screening, Risk Assessment and Plan of Care to Prevent Future Falls ProcessDomain: Person- and Caregiver-Centered Experience and Outcomes Kidney Disease Quality of Life (KDQOL) Survey OutcomeAdvance Care Plan ProcessICH-CAHPS: Nephrologists’ Communication and Caring OutcomeICH-CAHPS: Quality of Dialysis Center Care and Operations OutcomeICH-CAHPS: Providing Information to Patients OutcomeICH-CAHPS: Rating of Kidney Doctors OutcomeICH-CAHPS: Rating of Dialysis Center Staff OutcomeICH-CAHPS: Rating of Dialysis Center OutcomeDomain: Communication and Care Coordination ESCO Standardized Hospitalization Ratio for Admissions OutcomeESCO Standardized Readmission Ratio OutcomeMedication Reconciliation Post Discharge ProcessDomain: Clinical Quality of CareDiabetes Care: Eye Exam ProcessDiabetes Care: Foot Exam ProcessHemodialysis Adequacy: Minimum Delivered Hemodialysis Dose OutcomeProportion of Patients with Hypercalcemia OutcomePeritoneal Dialysis Adequacy: Delivered Dose of Peritoneal Dialysis Above Minimum OutcomeHemodialysis Vascular Access: Maximizing Placement of Arterial Venous Fistula ProcessHemodialysis Vascular Access: Minimizing Use of Catheters as Chronic Dialysis Access ProcessDomain: Population Health Influenza Immunization for the ESRD Population ProcessPneumonia Vaccination Status ProcessScreening for Clinical Depression and Follow-Up Plan ProcessTobacco Use: Screening and Cessation Intervention Process

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Change is here.It will be different in each communityHow will you prepare?What will you do?

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Abraham Lincoln

You cannot escape the responsibilityof tomorrow by evading it today.

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Appendix

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• Nearly 20 million US adults with CKD

• ESRD 0.9% of Medicare beneficiaries (<500,000), but about $31 billion in Medicare spending >7%)

• More than $85k per ESRD beneficiary (vs. ~$11k for all beneficiaries)

• Significant co-morbidities often present (depression, diabetes, CHF)

• “…An ounce of prevention”

Why ESRD Matters

ADC 2016 v11 - Annual Dialysis...

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