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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.
Outcomes and Analysis

We considered several outcomes that were based on benchmarks set by the National Kidney Foundation, including vascular access type, vaccination rates, and hospital readmission rates. Vascular access type among hemodialysis patients was defined as AVF, AVG, or CVC based on the access type used for the majority of treatments in each month and was expressed as the proportion of patients using each access type in each study period. Rates of pneumococcal vaccination were considered as the proportion of patients who had received the vaccination in the past 5 years or had received 2 doses ever. Influenza vaccination rates were determined as the annual period prevalence of patients (aggregated proportion) who received vaccinations between September 1 and March 31 within each study year. Hospital readmission rate was defined as the proportion of patients readmitted within 30 days of discharge following an inpatient stay.

We further considered healthcare costs, hospitalization and emergency department (ED) visit rates, length of stay, and hospitalized days. PMPM costs were considered, excluding dialysis treatment costs, and a 90-day claims run-out period was used to allow consistent data capture. Nondialysis medical costs included 4 categories: 1) inpatient hospital care costs, excluding inpatient care following kidney transplant; 2) professional medical care costs, defined as costs attributed to physician visits; 3) prescription drug costs; and 4) all other medical care costs, including but not limited to those of laboratory tests, SNFs, EDs, and home health care. Hospitalization and ED visit rates were calculated as the number of events per 1000 patient-years; length of hospital stay (days) and costs per admission were considered as the mean values in each study period. The total number of hospitalized days in the period was also determined. 

All outcomes were considered separately for commercial and MA members; no statistical comparisons were made. 


Payer beneficiaries receiving dialysis at the provider’s facilities in Pennsylvania were eligible for enrollment in the program; approximately 80% to 85% of eligible patients elected to enroll. Patient characteristics by type and year are summarized in the eAppendix Table (eAppendix available at Year to year, member characteristics were similar within each plan type. Overall, compared with commercial plan members, MA members tended to be older, have a greater burden of comorbidity, and have been on dialysis longer. 

Analysis of plan members with respect to the vascular access and vaccination outcomes that were part of the program performance metric is shown in Figure 1. Among both commercial and MA members, AVF and AVG utilization was greater in year 2 than at baseline, whereas CVC utilization was lower. Pneumococcal and influenza vaccination rates were consistently higher than 95% among both commercial and MA members across all study periods. 

Analyses of hospitalizations and ED visits are shown in Figure 2A and 2B. Among both member cohorts, the hospital admission rate declined over the study period. The length of stay for inpatient admissions also declined, from 6.4 days at baseline to 5.3 days in year 2 for commercial members and from 6.9 to 6.3 days, respectively, for MA members. The reductions in the hospital admission rate and length of stay resulted in a marked decline in the number of hospitalized days for plan members over the study period. 

Hospital readmission rates were moderately lower in year 2 than at baseline. Among commercial plan members, the rate fell from 22% at baseline to 18% and 19% in years 1 and 2, respectively. The readmission rate was 29% at baseline among MA members, declining to 24% and 25% in years 1 and 2, respectively. The ED visit rate among commercial members declined from 1377 to 864 visits per 1000 patient-years from baseline to year 2. For MA members, it declined from 2178 to 1305 visits per 1000 patient-years over the same period. 

Costs of medical care for program members also declined over the 2 years of the program (Figure 2C). In aggregate, more than $5 million was saved relative to the year 1 and year 2 actuarially determined cost expectations, with $3.04 million derived from the commercial members and $2.01 million from the MA members. Across the primary cost categories and considering both years, commercial members experienced a 48% decline in inpatient care costs, a 38% decline in professional costs, and a 34% decline in other medical expenses. For the MA members, these costs decreased by 19%, 9%, and 12%, respectively. The only exception to this trend toward decreasing costs was prescription drug costs, which increased from baseline through year 2 in both member cohorts (by 32% for commercial members and 30% for MA members). 

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