Dr Amal Agarwal: Value-Based Contracts Can Help Align Incentives in Dialysis


Amal Agarwal, DO, MBA, chief clinical officer at Monogram Health, explains the importance of value-based agreements in dialysis care, and the issue of dialysis prevalence among low-income and marginalized communities.

Amal Agarwal, DO, MBA, chief clinical officer at Monogram Health, talks about challenges in dialysis coverage, the disproportionate impact on marginalized communities, and how dialysis is not used today the way it was intended.


What challenges do dialysis providers and private insurers face in managing the costs of treating kidney failure?

Monogram Health does not provide dialysis; we actually remain dialysis agnostic. But prior to joining Monogram, I was at Humana for several years, and I was actually working in specialty contracts. One of the things we did was sign a value-based agreement with one of the large dialysis providers. And in that agreement, we had SLAs [service level agreements] to really focus on clinical outcomes and quality.

What that really did was create alignment between the provider and the insurance company that was around the patient. Some of the things we looked at was smooth transitions, reducing hospital starts, increasing home dialysis, increasing kidney transplants, [and] trying to control blood pressure and A1C. So I think these value-based contracts are a great tool to align those incentives.

How are low-income and marginalized communities disproportionately affected by the issue of dialysis coverage?

The real issue with the low-income and marginalized communities is actually the prevalence of dialysis. If you look at African Americans, there are 4 [times] more likely to start dialysis in these marginalized communities. Hispanics are 2.5 [times] more likely than Caucasian counterparts. So the real issue is, how do we get in there and address the prevalence of dialysis and slow down or stop that progression through good disease management?

Now, one of the things about dialysis that I think is really interesting was that it was actually created in the 1960s as a bridge to transplant. So dialysis was never meant to be curative—it was meant to be a short-term treatment until you get a transplant. In the 70s, legislation was signed that Medicare, the government, would cover the cost of dialysis for a small amount of people for a short period of time. Now you look forward to today, it's become synonymous with treatment and cure, and so it's very different than what it was intended to be.

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