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The American Journal of Managed Care November 2019
Comprehensive Health Management Pharmacist-Delivered Model: Impact on Healthcare Utilization and Costs
Leticia R. Moczygemba, PhD, PharmD; Ahmed M. Alshehri, PhD; L. David Harlow III, PharmD; Kenneth A. Lawson, PhD; Debra A. Antoon, BSPharm; Shanna M. McDaniel, MA; and Gary R. Matzke, PharmD
One Size Does Not Always Fit All in Value Assessment
Anirban Basu, PhD; Richard Grieve, PhD; Daryl Pritchard, PhD; and Warren Stevens, PhD
Value Assessment and Heterogeneity: Another Side to the Story
Steven D. Pearson, MD, MSc
From the Editorial Board: Joshua J. Ofman, MD, MSHS
Joshua J. Ofman, MD, MSHS
Multimodality Cancer Care and Implications for Episode-Based Payments in Cancer
Suhas Gondi, BA; Alexi A. Wright, MD, MPH; Mary Beth Landrum, PhD; Jose Zubizarreta, PhD; Michael E. Chernew, PhD; and Nancy L. Keating, MD, MPH
Medicare Advantage Plan Representatives’ Perspectives on Pay for Success
Emily A. Gadbois, PhD; Shayla Durfey, BS; David J. Meyers, MPH; Joan F. Brazier, MS; Brendan O’Connor, BA; Ellen McCreedy, PhD; Terrie Fox Wetle, PhD; and Kali S. Thomas, PhD
Currently Reading
CKD Quality Improvement Intervention With PCMH Integration: Health Plan Results
Joseph A. Vassalotti, MD; Rachel DeVinney, MPH, CHES; Stacey Lukasik, BA; Sandra McNaney, BS; Elizabeth Montgomery, BS; Cindy Voss, MA; and Daniel Winn, MD

CKD Quality Improvement Intervention With PCMH Integration: Health Plan Results

Joseph A. Vassalotti, MD; Rachel DeVinney, MPH, CHES; Stacey Lukasik, BA; Sandra McNaney, BS; Elizabeth Montgomery, BS; Cindy Voss, MA; and Daniel Winn, MD
A scalable chronic kidney disease (CKD) quality improvement intervention demonstrated feasibility, decreased hospitalization, and reduced costs. These preliminary results support innovation in CKD by commercial health plans.
ABSTRACT

Objectives: To execute a chronic kidney disease (CKD) intervention to assess feasibility and preliminary outcomes for a health plan.

Study Design: This CKD quality improvement study was incorporated into an existing CareFirst primary care patient-centered medical home cohort with a pre- and postintervention assessment from July 1, 2015, to June 30, 2017.

Methods: The study targeted the population at risk for CKD with diabetes and/or hypertension by implementing a care plan according to the stratification by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR) or CKD heat map class.

Results: The population included 7420 individuals (51.8% female) with a mean age of 55.9 years; 19.1% had diabetes only, 42.2% had hypertension only, and 38.2% had both conditions. Overall, there was no change in eGFR testing among risk groups (84.8%), but a small significant increase in uACR testing occurred (from 31.3% to 33.0%; P = .0020). Reductions in admissions per 1000 patients were from 362.5 to 249.0 for class 3, 311.7 to 219.2 for class 4, and 590.9 to 323.5 for class 5. Lastly, there were reductions in 30-day readmissions per 1000 patients, from 51.9 to 13.7 for class 4 and 45.5 to 0 for class 5. Although there were increases in many of the per-member per-month costs assessed pre- versus post intervention, net savings in medical costs were $276.80 and $480.79 for CKD classes 3 and 5, respectively.

Conclusions: This scalable CKD intervention demonstrated feasibility. For advanced CKD, decreased hospitalization and a reduction in several important costs were observed. These preliminary results support the stratification of laboratory data for CKD population health innovation in commercial health plans.

Am J Manag Care. 2019;25(11):e326-e333
Takeaway Points
  • Previous studies show underdiagnosis of chronic kidney disease (CKD) in primary care.
  • The CKD major risk groups include patients with diabetes and patients with hypertension.
  • The severity of CKD is assessed by tests for kidney function and kidney damage that predict hospitalization, adverse cardiovascular and kidney disease outcomes, and expenditures.
  • A CKD quality improvement study designed to implement care based on test result severity in a health plan’s patient-centered medical home adult population confirmed incomplete testing for CKD but still reduced hospitalizations and lowered selected expenditures over 24 months of follow-up.
  • Commercial health plans should consider CKD population health innovations.
Gaps in the implementation of clinical practice guidelines for the testing, recognition, and management of chronic kidney disease (CKD) in primary care are common and represent opportunities for quality improvement and patient safety interventions.1-4 CDC population surveys show that CKD affects 37 million (15%) adults in the United States, and the at-risk population includes 156 million with hypertension and 114 million with diabetes or prediabetes.5 A CDC analysis demonstrated that CKD screening among patients with these conditions was cost-effective.6 Additionally, CKD is a disease multiplier that often occurs with other chronic comorbidities and also increases the risk of emergency department (ED) visits, hospitalizations, cardiovascular events, kidney failure, and death.7,8 In 2016, total Medicare expenditures for kidney disease were more than $114 billion, including $79 billion for all stages of diagnosed CKD (an annual increase of 23%) and $35 billion for end-stage renal disease (ESRD), which is treated with dialysis or kidney transplant.9 In addition to the Medicare expenditures, commercial insurance costs for kidney disease greatly exceed Medicare’s costs of $114 billion annually, supported by a recent study that showed differences in mean per-patient per-year costs, which were $76,969 versus $46,178 for advanced CKD stages and $121,948 versus $87,339 for ESRD in the commercial and Medicare groups, respectively.10 Thus, CKD is common, identifiable, and associated with high morbidity, mortality, and cost. Addressing the existing gaps in the timely recognition and management of CKD should improve outcomes11-13 and limit costs.9,10 Because the core elements of CKD testing and risk stratification are quantifiable electronically, previous studies have demonstrated the effectiveness of transforming practices to a population health model for CKD.14-21

In general, improvements in care quality, patient outcomes, and the cost-effectiveness of care can arise through the process of continuous quality improvement and the implementation of population health management models that leverage health informatics, team-based care, and strategies for organizational change.22 CareFirst BlueCross BlueShield (CareFirst) is a nonprofit health plan serving as the largest healthcare insurer in the mid-Atlantic region with more than 3.2 million beneficiaries. CareFirst initially determined CKD as frequently underdiagnosed and elevated serum creatinine as the most significant laboratory cost driver across the member population compared with other laboratory tests, including hyperglycemia, hypercholesterolemia, and liver function test abnormalities (eAppendix A [eAppendices available at ajmc.com]). CareFirst then began collaborating with CKDintercept, the CKD primary care initiative of the National Kidney Foundation (NKF), to design a quality improvement study to test the impact of a CKD intervention in the primary care setting.

METHODS

The collaboration resulted in a quality improvement study design with 3 key elements: testing the at-risk population with diabetes and/or hypertension, detection of CKD, and care plan implementation individualized to the risk stratification by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR) based on clinical practice guidelines. The study objectives were to determine feasibility of implementation and preliminary outcomes. Long-term aims included promoting CKD diagnosis, reducing cardiovascular risk, slowing CKD progression, increasing timely and appropriate nephrology consultation, and reducing costs.

The intervention was integrated into CareFirst’s patient-centered medical home (PCMH) model, developed in 2011 to control the rising healthcare costs in Maryland, northern Virginia, and the District of Columbia (DC). At the time of the study, approximately 1.2 million CareFirst beneficiaries and about 4500 primary care physicians (PCPs) were enrolled in the CareFirst PCMH program. The PCPs are incentivized for providing, arranging, coordinating, and managing quality, efficient, and cost-effective healthcare services for members. The program provides a combination of data sharing, clinical support, and incentives with the goal of improving quality of care and reducing costs over time.

PCPs voluntarily participate in the PCMH program, which is characterized by registered nurse care coordinator support, analytical support including a registry function, web-based tools for care coordination, and upside-only incentives for achieving quality and cost containment. Local care coordinators (LCCs) work closely with PCPs to identify, screen, and monitor CareFirst members who have indicators of CKD. Each LCC reviews the laboratory results of identified members with the attributed PCP to assign each to the appropriate CKD class, as defined by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines.11,12 The assigned CKD class aids the PCP to decide on an appropriate course of treatment, the need for a care plan, the frequency of kidney function monitoring, and the timing of referral to kidney care specialists and other related community-based resources.


 
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