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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
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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
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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
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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.
DISCUSSION

Management of patients with ESRD is difficult, requiring frequent and routine access to patients, partnership with nephrologists, specialized care protocols, and customized technology. In an effort to improve outcomes and lower costs, a dialysis provider and a payer created a shared savings incentive program. Members enrolled in the program were provided targeted services aimed at improving specific quality metrics and controlling nondialysis healthcare expenditures. 

As shown here, this payer–provider partnership resulted in improved clinical care quality metrics and reduced medical costs relative to the baseline population. Improvements were observed in vascular access utilization, with an increase in AVF and AVG utilization and a decrease in CVC utilization among both commercial and MA members. Vaccination rates for influenza and pneumococcus were above 95% for both member cohorts across the study period. These vaccination rates are substantially higher than those most recently reported for the Medicare ESRD population generally (30% for pneumococcus1 and 75% for influenza9).

Hospitalizations are a major cost driver among the ESRD population. Notably, the hospital admission rate, number of hospitalized days, ED visit rate, and 30-day readmission rate all decreased following the inception of the payer–provider partnership, and these decreases were accompanied by decreases in inpatient costs and healthcare costs overall. The hospital admission rate for MA program members in year 2 (1.3 admissions/patient-year) compares favorably with the rate for the Medicare hemodialysis population overall, which averaged 1.69 admissions per patient-year in 2013.1 The hospital readmission rate for MA program members in year 2 (25%) was markedly lower than the Medicare average (36.9% in 2013).1 Our findings are consistent with prior evidence demonstrating that care coordination can improve outcomes and may help contain costs for patients with ESRD.7,10

Although overall costs and inpatient costs declined among plan members, our analyses documented incremental increases in overall medication costs during years 1 and 2 compared with the baseline period. This result may be related to improved patient adherence to prescribed medications arising from enhanced clinical management. Alternatively, this observation may have been driven by a small number of patients receiving treatment with extremely expensive medications; further analysis will be required to fully understand this result. 

Limitations

Several factors may limit the generalizability of our findings to other ESRD populations. First and foremost, this was a retrospective observational analysis that was not designed to address cause-and-effect relationships. The patient population studied was defined by the patients’ choice of payer and provider and their willingness to enroll in the program. These factors, along with annual changes in membership and patient attrition, must be taken into consideration when interpreting our findings. Additionally, geography has been shown to influence healthcare spending,10 as well as dialysis access and modality1; our study was limited to patients who received treatment in Pennsylvania.

CONCLUSIONS

The promising trends observed among members participating in this payer–provider ESRD population health partnership suggest that collaborations with shared incentives may be a valuable approach for improving ESRD patient outcomes and reducing care costs. 

Acknowledgments 
The authors acknowledge the medical writing assistance of Dena E. Cohen, PhD. The authors thank Carly Busch, Sarah Falkof, and John Plonka for assistance with data acquisition.

Author Affiliations: DaVita, Inc (JK, DR, SM), Denver, CO; Highmark, Inc (RW), Pittsburgh, PA.

Source of Funding: Manuscript editorial support was provided by DaVita, Inc. There was no source of funding for the study itself.

Author Disclosures: Mr Kindy, Dr Roer, and Dr McMurray are employed by DaVita, which is party to the agreement and receives shared savings payments on program results. Dr Roer has attended meetings or conferences of the American Society of Nephrology, Renal Physicians Association, and Capability Maturity Model Integration. Dr Wanovich is employed in a full-time management position at Highmark, Inc, the payer discussed in the manuscript. Dr McMurray reports stock ownership in DaVita, Inc. 

Authorship Information: Concept and design (JK, DR, RW, SM); acquisition of data (RW); analysis and interpretation of data (JK); drafting of the manuscript (DR, SM); critical revision of the manuscript for important intellectual content (JK, DR, RW, SM); and administrative, technical, or logistic support (RW).

Address Correspondence to: Justin Kindy, FSA, MAAA, DaVita, Inc, 2000 16th St, Denver, CO 80202. Email: justin.kindy@davita.com.
REFERENCES

1. The United States Renal Data System 2015 annual data report. United States Renal Data System website. usrds.org/2015/view. Published 2015. Accessed July 1, 2016. 

2. Nissenson AR. Delivering better quality of care: relentless focus and starting with the end in mind at DaVita. Semin Dial. 2016;29(2):111-118. doi: 10.1111/sdi.12462.

3. Wilson SM, Robertson JA, Chen G, et al. The IMPACT (Incident Management of Patients, Actions Centered on Treatment) program: a quality improvement approach for caring for patients initiating long-term hemodialysis. Am J Kidney Dis. 2012;60(3):435-443. doi: 10.1053/j.ajkd.2012.04.009.

4. Wilson SM, Mayne TJ, Krishnan M, et al. CathAway fistula vascular access program achieves improved outcomes and sets a new standard of treatment for end-stage renal disease. Hemodial Int. 2013;17(1):86-93. doi: 10.1111/j.1542-4758.2012.00721.x.

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6. Nissenson AR, Deeb T, Franco E, Krishnan M, McMurray S, Mayne TJ. The ESRD Demonstration Project: what it accomplished. DaVita Inc. Nephrol News Issues. 2011;25(7):39-41.

7. Krishnan M, Franco E, McMurray S, Petra E, Nissenson AR. ESRD special needs plans: a proof of concept for integrated care. Nephrol News Issues. 2014;28(12):30,32,34-36.

8. Goroff M, Reich MR. Partnerships to provide care and medicine for chronic diseases: a model for emerging markets. Health Aff (Millwood). 2010;29(12):2206-2213. doi: 10.1377/hlthaff.2009.0896.

9. McCullough PA, Barnhart HX, Inrig JK, et al. Cardiovascular toxicity of epoetin-alfa in patients with chronic kidney disease. Am J Nephrol. 2013;37(6):549-558. doi: 10.1159/000351175.

10. Gottlieb DJ, Zhou W, Song Y, Andrews KG, Skinner JS, Sutherland JM. Prices don’t drive regional Medicare spending variations. Health Aff (Millwood). 2010;29(3):537-543. doi: 10.1377/hlthaff.2009.0609.
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