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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
Cost Sharing and Branded Antidepressant Initiation Among Patients Treated With Generics
Jason D. Buxbaum, MHSA; Michael E. Chernew, PhD; Machaon Bonafede, PhD; Anna Vlahiotis, MA; Deborah Walter, MPA; Lisa Mucha, PhD; and A. Mark Fendrick, MD
The Well-Being of Long-Term Cancer Survivors
Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
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A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis
Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Limited Distribution Networks Stifle Competition in the Generic and Biosimilar Drug Industries
Laura Karas, MD, MPH; Kenneth M. Shermock, PharmD, PhD; Celia Proctor, PharmD, MBA; Mariana Socal, MD, PhD; and Gerard F. Anderson, PhD
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis

Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
A report on the clinical and economic outcomes of a new payer–provider partnership serving patients with end-stage renal disease.

Objectives: Patients with end-stage renal disease (ESRD) are clinically complex, requiring intensive and costly care. Coordinated care may improve outcomes and reduce costs. The objective of this study was to determine the impact of a payer–provider care partnership on key clinical and economic outcomes in enrolled patients with ESRD.

Study Design: Retrospective observational study.

Methods: Data on patient demographics and clinical outcomes were abstracted from the electronic health records of the dialysis provider. Data on healthcare costs were collected from payer claims. Data were collected for a baseline period prior to initiation of the partnership (July 2011-June 2012) and for two 12-month periods following initiation (April 2013-March 2014 and April 2014-March 2015).

Results: Among both Medicare Advantage and commercial insurance program members, the rate of central venous catheter use for vascular access was lower following initiation of the partnership compared with the baseline period. Likewise, hospital admission rates, emergency department visit rates, and readmission rates were lower following partnership initiation. Rates of influenza and pneumococcal vaccination were higher than 95% throughout all 3 time periods. Total medical costs were lower for both cohorts of members in the second 12-month period following partnership initiation compared with the baseline period. 

Conclusions: Promising trends were observed among members participating in this payer–provider care partnership with respect to both clinical and economic outcomes. This suggests that collaborations with shared incentives may be a valuable approach for patients with ESRD.

Am J Manag Care. 2018;24(4):204-208
Takeaway Points
  • Payer–provider partnerships have been proposed as a means to improve patient outcomes and reduce healthcare costs among patients requiring complex, coordinated care. Here, we report the outcomes of such a partnership established to care for patients with end-stage renal disease (ESRD). 
  • In the 2 years following the initiation of the partnership, both Medicare Advantage and commercial insurance patients showed improvements in the proportion of patients dialyzing with a permanent vascular access, hospital and emergency department utilization, and total healthcare expenditures. 
  • Coordination of care through partnership programs may be of significant benefit to patients with ESRD.
Patients with end-stage renal disease (ESRD) require extensive, complex, and costly medical care. Life-sustaining dialysis treatments, often administered as thrice-weekly hemodialysis, rid the body of the toxins and fluids normally removed from the blood by the kidneys. In 2013, although patients with ESRD represented less than 1% of the US Medicare population, they accounted for approximately 7% of Medicare fee-for-service expenditures, with an annual average cost of $84,550 per patient.1 On average, patients with ESRD were hospitalized 1.69 times per year in 2013, and approximately one-third of those hospitalized were readmitted within 30 days of discharge,1 making hospitalizations a major cost driver in this population.

Intensive patient management by dialysis providers and their partner nephrologists has been shown to improve outcomes among patients with ESRD2 and may simultaneously reduce costs. For example, the method used to access the patient’s circulatory system for dialysis has a strong association with outcomes: arteriovenous grafts (AVGs) or arteriovenous fistulae (AVFs) have a lower rate of infections and other complications compared with central venous catheters (CVCs). Thus, patient management at the time of dialysis initiation3 and initiatives to increase the use of AVFs and minimize use of CVCs4 have been associated with improved outcomes and lower costs. Patient management programs can also enhance adherence to complex medication regimens.5

Mechanisms for delivering coordinated care to patients with ESRD include federally funded experimental models such as the CMS ESRD Management Demonstration Project,6 special needs plans,7 and, most recently, ESRD Seamless Care Organizations. In the private sector, payer–provider partnerships have been proposed as a means to provide high-quality and cost-effective care for patients with chronic illnesses, including ESRD.8

Recently, a payer and a provider (a subsidiary of a large dialysis organization) initiated a contractual partnership with the goal of improving care and reducing costs for patients with ESRD who were receiving their dialysis treatments at the provider’s facilities in Pennsylvania. The payer's claims data combined with the provider’s analytic capabilities enabled the use of risk stratification and predictive models to target patients for specific interventions. These included supplemental care pathways and clinical protocols targeting specific objectives, such as transitioning patients from CVCs to AVFs, reducing hospitalizations, and decreasing the frequency of readmissions. Field-based renal nurse care managers supported fluid management, immunizations, nutritional supplementation, and end-of-life counseling. Both Medicare Advantage (MA) and commercial insurance members were eligible for the program, which used a shared savings model to create economic incentives for the partners. Incentive payments were contingent on the provider meeting or exceeding United States Renal Data System quality benchmarks for rates of AVF and CVC use, influenza and pneumococcal pneumonia  vaccination, and hospital readmissions. Savings were calculated by comparing the actual total cost of care with a predetermined, actuarially derived expected total cost of care. Incentive payments constituted a contractually stipulated portion of the calculated savings. Here, we report an observational analysis of outcomes and costs of care during the first 2 years of the partnership. 


Study Design

We conducted an observational analysis of outcomes and costs among a payer’s plan members receiving dialysis through a specific provider. The payer’s MA and commercial insurance members were analyzed separately. Two consecutive 12-month periods (April 1, 2013-March 31, 2014 and April 1, 2014-March 31, 2015) following initiation of the partnership were compared with a 12-month baseline period (July 1, 2011-June 20, 2012). We excluded patients who 1) were in the top 1% in terms of total annual aggregated nondialysis costs, 2) were missing dialysis/inpatient/skilled nursing facility (SNF) claims in at least 50% of the identified eligible member months, 3) had dialysis/inpatient/SNF claims of less than $1500 (commercial) or $1000 (MA) per member per month (PMPM) in at least 50% of eligible member months, or 4) received a kidney transplant (exclusion began in the month that the transplant was received).

Data Sources 

This retrospective, observational, noninterventional analysis of outcomes in patients in the partnership was conducted using existing deidentified patient data; therefore, according to the HHS regulations, 45 CFR Part 46, this study was exempt from institutional review board or ethics committee approval. We adhered to the Declaration of Helsinki and informed consent was not required.

Demographic information and clinical data in each study period were abstracted from the electronic health records of the dialysis provider. Comorbidities were determined from patient utilization within the payer claims database using International Classification of Diseases, Ninth Revisiondiagnosis codes. Payer claims were used to determine healthcare costs. 

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