Making the Money Follow the Consensus in Nephrology Payment Reform

Nephrology has recently been reinvigorated to address social determinants of health to reduce the incidence and progression of kidney diseases, with opportunities ranging from broader availability of genetic testing for specific kidney disease etiologies to the availability of novel kidney and cardiovascular protective medications to the development and accessibility of precision therapy for apolipoprotein-1 nephropathy. These exciting advances in clinical science have yet to yield improved population health because of several challenges, including disincentives leading to poor adoption of CKD interventions, default use of in-center hemodialysis, and in turn poor access to home dialysis and preemptive kidney transplant. Disparities in care exist across the spectrum of CKD severity. Reimbursement reform is an approach to improve care.

The Merit-Based Incentive Payment System (MIPS) program is administered by the Centers for Medicare & Medicaid Services (CMS) to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. The program, however, is potentially incompletely understood, despite several factors that emphasize its importance in practice, including the role of eliminating disparities. All nephrology clinicians who manage Medicare recipients participate in the program and can even be unknowingly enrolled in MIPS by the group (practice or health system) reporting option in the absence of alternative payment models (APM) participation or individual MIPS selection. Because ESKD confers Medicare eligibility, with 83.9% of patients initiating in-center hemodialysis modality in 2020,¹ quality measures have historically been focused on this population to address associations of in-center hemodialysis with disproportionate spending and poor clinical outcomes. In-center hemodialysis measures are predominantly a part of the ESKD Quality Improvement Program at the facility level, outside of MIPS. To date, nephrology participation in MIPS has been limited by administrative complexity and few quality measures that are relevant to nephrology practice.² However, the silver lining of the historic dearth of CKD, home dialysis, and kidney transplant quality improvement measures is that there is now a preventive and more patient-centric opportunity to develop a quality improvement portfolio. These opportunities that would finally be designed to reduce CKD progression improve preparation for kidney failure replacement therapy, with an overall effect of fewer patients requiring dialysis and progress in efforts to minimize the current disparate outcomes in kidney care.

Such an opportunity is described by Tummalapalli et al. with the American Society of Nephrology (ASN) Quality Committee iterative consensus building process, from May 2020 to July 2022, to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP) or menu of quality measures to address these limitations.³ Two rounds of ranked-choice voting among its members were used to select eight quality metrics, 13 improvement activities, and two cost measures for incorporation into the MVP. Refinement included collaboration with the CMS MVP Development Team and favorable public comments that culminated in the MVP submission through CMS's Measures Under Consideration process. The development of the Optimal Care for Kidney Health MVP highlights the importance of collaborative policymaking between subspecialty professional organizations and national regulatory agencies. The ASN Quality Committee's iterative consensus building process is an excellent model of how stakeholders can work together to develop a quality assessment program that is relevant, effectively meaningful, and evidence-based to improve outcomes.

Nephrologists who participate in the Optimal Care for Kidney Health MVP will have the option of selecting four of eight quality measures, participate in a patient-centered medical home or choose two medium-weighted or one high-weighted measure(s) of 13 improvement activities, participate in both cost measures specific to nephrology, use one of two population health measures, and elect one of 16 promoting interoperability measures. Of note, participation in the three highest ranked quality measures is encouraged, including angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy, Optimal ESKD Starts, and hypertension control. Nephrologists will also continue to have the choice of participating in traditional MIPS election or APM as before. Overall, this is an important incremental step forward for nephrology payment reform because it streamlines measures while increasing relevance to practice.

The authors accurately list the shortcomings of their process, including the paucity of quality metrics to capture aspects of CKD care; no performance metrics for recently described highly effective agents; inadequate performance metrics for anemia, mineral and bone disease, vascular access, kidney disease education, and CKD quality of life; absence of kidney transplant measures; and absence of patient involvement. The authors also note the exclusion of dedicated health equity measures as a limitation in the development of the pathway. Finally, the authors address the challenges faced by nephrology clinicians in small or rural practices or those that care for disadvantaged patients. Nephrology practices with fewer resources will be less nimble to implement the necessary clinic redesign for MVP participation and may be indirectly penalized by the pathway and other measures that confer greater challenges in data collection and high performance in their practice settings. Quality measures are harder to achieve when populations have significant social needs as well as medical complexity. The authors suggest that MIPS can support these clinicians by providing resources and education to improve data collection and reporting. Although the Optimal Care for Kidney Health MVP should allow for stratification of measures to evaluate performance across relevant disadvantaged groups, the authors also recommend future development of screening social determinants of health measures to foster health equity interventions to connect the vulnerable populations to community-based resources.

A particular limitation is the lack of measures that reflect the most important recent innovations in kidney care. The developers note that the absence of sodium–glucose cotransporter-2 (SGLT-2) inhibitor measure as a particularly unfortunate limitation, as SGLT-2 inhibitors are arguably the most important innovation in slowing CKD progression since the publication of the Reduction of End Points in NIDDM with the Angiotensin II Antagonist Losartan Study and Irbesartan Diabetic Nephropathy Trial in 2001.^4,5 SGLT-2 inhibitors are associated with remarkably statistically significant reductions in both CKD progression and heart failure hospitalization for patients with diabetic and nondiabetic CKD.^6–8 In addition, the nonsteriodal mineralocorticoid receptor antagonist has shown similar improvements in the same outcomes in the type 2 diabetes population with CKD.^9,10 Health services research has already demonstrated inequities in access to these therapies,¹¹ and there is a missed opportunity in not leveraging this aspect of relevant practice. However, the foundation to mitigate the limitations may still be built. Albuminuria predicts response to these agents in the kidney outcome trials with clinical practice guidelines recommending prioritization of those with A2 and A3 albuminuria.¹² For example, the Study of Heart and Kidney Protection with Empagliflozin trial demonstrated no significant primary composite outcome benefit in those with A1 albuminuria, and the finerenone trials required urine albumin–creatinine ratio > 30 mg/g for enrollment.^8–10 As such, building an intervention measure on the existing Kidney Health Evaluation, which requires annual eGFR and urine albumin–creatinine ratio testing for adults with diabetes, is conceptually attractive. In addition, interdisciplinary care with a dietitian or diabetes educator could be built on the kidney health evaluation for the population with eGFR <60 m/min per 1.73 m² eligible for medical nutrition therapy according to CMS reimbursement policy. Incorporating kidney failure replacement modality education as an intervention on the basis of the results, such as eGFR <30 ml/min per 1.73 m² or CKD G4 and 5, is also conceptually attractive. Broadening the denominator for the kidney health evaluation to include hypertension in addition to diabetes would greatly increase the population reached by the measure and in turn the population that would benefit from drug, interdisciplinary, and educational interventions on the basis of the results of the testing. Overall, matching eGFR to uACR results to interventions is a step toward relevant and high-quality care.

The Optimal Care for Kidney Health MVP developed by the ASN Quality Committee is an important incremental milestone in the assessment of kidney care delivery for nephrologists to promote participation. By including measures specific to nephrology care, the MVP is expected to be more relevant and meaningful in assessing kidney care delivery. It will facilitate better performance comparison across nephrology practices and enable continuous improvement in the quality of kidney care delivery. Moreover, the MVP will promote the adoption of evidence-based practices that have been shown to improve the outcomes of patients with kidney disease.

Regarding future steps for reform, the authors note that participation in the Optimal Care for Kidney Health MVP pathway is currently optional in 2023, but CMS has indicated that it will become mandatory after 2026. Over time, APMs are also anticipated to expand. The results from the Kidney Care Choices APM that ends in December 2026 will inform future iterations of APMs for kidney diseases. Monitoring of the Optimal Care for Kidney Health MVP may inform modification of MIPS measures according to the effect on quality of care, costs, administrative burden and health equity. Future incorporation of health equity and SGLT-2 inhibitor measures must follow.

Disclosures

J.A. Vassalotti reports Consultancy: RenalytixAI, plc. Advisory Board—type-2 diabetes and CKD biomarkers and artificial intelligence (honoraria), Astra Zeneca, Inc.—consultant—CKD and SGLT-2 inhibitor and potassium binder use (honoraria); Honoraria: RenalytixAI, plc. Advisory Board—CKD biomarkers and artificial intelligence (honoraria), Astra Zeneca, Inc.—consultant—CKD and SGLT-2 inhibitor and potassium binder use; and Advisory or Leadership Role: Chief Medical Officer of National Kidney Foundation. The remaining author has nothing to disclose.

Funding

None.

Author Contributions

Conceptualization: Mukta Baweja, Joseph A. Vassalotti.

Writing – original draft: Mukta Baweja, Joseph A. Vassalotti.

Writing – review & editing: Mukta Baweja, Joseph A. Vassalotti.