Preparing the Nephrology Workforce for the Transformation to Value-Based Kidney Care

Introduction

On July 10, 2019, the Department of Health and Human Services announced the historic kidney care strategy Advancing American Kidney Health (AAKH), which has three tangible goals: (1) reducing incident ESKD by 25% by 2030, (2) having 80% of patients with incident ESKD receiving home dialysis or a transplant in 2025, and (3) doubling the number of kidneys available for transplant by 2030. With this announcement, the kidney community has been tasked with designing and implementing programs to improve CKD and ESKD management and reduce costs. Coming after years of advocacy efforts and committed work from patient and professional organizations, there is hope that this announcement marks the beginning of the end of the current status quo of kidney care.

The Value-Based Transformation of Kidney Care

We believe that achieving these high-reaching initiatives will require investment in a nephrology workforce that fills two critical needs: (1) clinical leaders to implement kidney care delivery interventions and (2) researchers to evaluate the effectiveness of new policies and programs. In this perspective, we focus on workforce training in relation to the first two AAKH goals and propose a roadmap to accelerate AAKH efforts by training implementation leaders and health services researchers and recruiting for the future.

The Need for Implementation Leaders

Nephrology has had a long history of early adoption of value-based payment models, which have previously focused on ESKD, including the ESRD Prospective Payment System, the ESRD Quality Incentive Program (QIP), and ESRD Seamless Care Organizations (ESCOs). The AAKH initiatives expand the scope by spanning the spectrum of kidney disease from CKD to ESKD to transplant. To achieve the shared goal of reducing incident ESKD, care delivery interventions will need to concentrate on CKD care, which poses opportunities and challenges. In contrast to ESKD care, which is highly consolidated and systematically tracked by the US Renal Data System and the ESKD QIP for research and quality evaluation, CKD care is highly fragmented. Moreover, CKD is not reliably identified by International Classification of Diseases-10 codes in claims databases, we lack CKD-specific quality measures, and we lag in systematic implementation of multidisciplinary care to include primary care providers and other specialists.

Despite evidence-based strategies to evaluate and manage CKD, quality of care gaps and suboptimal chronic disease management in CKD contribute to disease progression. Reducing incident ESKD will require nephrologists to implement population health strategies for CKD in collaboration with other members of the care team. We recommend consideration of three initiatives to develop nephrology implementation leaders: (1) support faculty with dedicated time for implementing kidney care delivery interventions, (2) cultivate roles and relationships with health systems leadership, and (3) design and implement a nephrology-specific quality improvement (QI) curriculum.

Developing Local and Health System Leadership in Implementing Alternative Payment Models in CKD and ESKD

First, to realize the potential of health care delivery interventions in kidney disease care, hospital, division, and practice leaders need to reserve protected time for nephrologists to lead kidney care delivery changes. The new alternative payment models that extend to CKD now provide a “business case” for dedicating nephrologist time to CKD care improvement. For example, nephrology practices and entities participating in the optional Kidney Care First and Comprehensive Kidney Care Contracting models will receive adjusted capitated payments for patients with CKD stages 4 or 5 or on dialysis and bonus payments for patients who receive a transplant. These additional payments could be invested in care coordination efforts, multidisciplinary clinic staff, and protected time for nephrologists leading population health programs that slow CKD progression and delay dialysis initiation.

Second, establishing relationships and cultivating nephrologists in leadership roles are crucial to improve kidney care within the health system. Nephrologists have historically been prominent in academic medicine departmental leadership, and some hold health system leadership positions in quality and population health departments. A larger nephrology workforce with this level of experience would place emphasis on the priorities of patients with kidney disease and allow for an intricate understanding of payment structures to facilitate the AAKH goals. For example, partnering with health system informatics could expedite the creation of registries, e-consultation, and clinician decision support tools for CKD management (1). Nephrologists could build partnerships with primary care to build CKD early detection and comanagement programs, with the goal of reducing incident ESKD.

Nephrology-Specific QI Curricula

Expanding CKD care management, home dialysis utilization, and transplant referrals and workup among other initiatives will be an iterative process and require continuous improvement using QI principles. Although many nephrologists are already engaged in QI activities and hold quality leadership roles, such as serving as medical directors of dialysis units, few have received formal training in QI (2). In nephrology fellowship programs, QI has been an Accreditation Council for Graduate Medical Education requirement since 2011, although the performance of fellowships in QI engagement has not been systematically assessed. We propose that all nephrology fellows and interested faculty be taught a core curriculum of nephrology-specific QI content. National professional societies, such as the American Society of Nephrology (ASN), the National Kidney Foundation, and the Renal Physicians Association, could develop nephrology quality core curricula, which have been successfully implemented in other medicine subspecialties (3). Few nephrology-specific QI curricula have been published, and as more engage in QI training, additional educational materials should be disseminated (4). Nephrology-specific quality content would include nephrology-relevant quality measures and nephrology payment models in CKD and ESKD. Participants in the curriculum should be assessed on their QI knowledge and engagement using existing instruments (5,6). For instance, a QI curriculum could improve home dialysis rates by teaching nephrologists-in-training about home-related payment adjustments and providing the tools to design and refine QI interventions to improve home modality uptake. Similarly, QI initiatives in dialysis facilities to standardize and expedite transplant referral may improve transplant rates and generate payment incentives in the ESRD Treatment Choices model.

Select fellows could elect to participate in a specialized training pathway during elective time in their second year or in a third fellowship year, which would consist of health care delivery immersion experiences and an advanced curriculum covering related fields of leadership, advocacy, and public policy (7). These dedicated tracks would offer experiences working with hospital leadership on quality projects relevant to nephrology and aligned with AAKH and health system priorities. Because nephrology divisions may lack sufficient QI expertise, nephrology-specific QI curricula and QI fellowships should be housed within academic medical centers and may be in conjunction with other internal medicine subspecialties. Trainee rotational experiences with ESCOs, payors, and policy makers could provide insights in care coordination and cost reduction to apply to the clinical setting.

Training Health Services Researchers

Expanding health services research in nephrology is an imperative to rigorously evaluate the effectiveness of care delivery and policy changes to improve outcomes, reduce costs of care, and assess for unintended consequences. Implementation science, the study of “the uptake of research findings and other evidence-based practices into routine practice,” in academic nephrology is in its infancy, and the ASN has called for additional study of interventions via implementation science and the expansion of pragmatic trials (8,9). Realizing the potential of health services research in nephrology will require (1) investments from funding sources and (2) formal collaborations with other disciplines to cultivate junior and senior investigators in this area.

First, training health services researchers in nephrology will require substantial investments from government and professional organizations to sponsor career development awards and established investigator awards. Sponsorship of research awards requires the recognition that health services research is a key component to support evidence-based policy evaluation. For example, research in implementation science could evaluate new electronic health record–based interventions and education tools for patients with late-stage CKD. Researchers in health economics can evaluate the effect of capitated payments on dialysis initiation and the cost-effectiveness of new care models. A coordinated approach from professional organizations, the National Institutes of Health, and the Agency for Healthcare Research and Quality would ensure dedicated funds toward health services research.

Second, formal collaborations between nephrology divisions and health services researchers in other disciplines will cultivate more mentors for early career health services researchers in nephrology. Aligning with transdisciplinary institutes in health services research and health policy can serve as a source of this mentorship.

Recruiting for the Future

These sweeping policy changes in kidney care come at a time where nephrology continues to face critical workforce shortages. Nephrology fellowship programs can harness the historic policy changes to recruit nephrology applicants with experience in QI, leadership, and policy. Current nephrology applicants trained to be physicians in the midst of a quality revolution, and a growing number have MD/MBA or MD/MPP joint degrees (10). By positioning itself as a predominant specialty where quality of care, value, and population health are a central focus, nephrology could potentially recruit residents with an interest in health care delivery implementation and health services research.

Improving our capacity for implementation and evaluation will require the dedicated coordination between nephrology divisions, fellowship training programs, national societies, and funding sources. The future of nephrology care delivery has arrived. A nephrology workforce equipped to improve and research the quality of kidney disease care is needed to advance kidney health in the value-based era.

Disclosures

Dr. Peralta has ownership in and is Chief Medical Officer of Cricket Health, Inc. Dr. Tummalapalli has nothing to disclose.

Funding

Dr. Tummalapalli is supported by the ASN Foundation for Kidney Research Ben J. Lipps Research Fellowship Program (Sharon Anderson Research Fellowship) and University of California, San Francisco Philip R. Lee Institute for Health Policy Studies Jonathan A. Showstack Career Advancement Award in Health Policy/Health Services Research. Dr. Peralta is supported by National Institute on Aging grant R01AG046206, National Institute of Diabetes and Digestive and Kidney Diseases grant R18DK110959, and an American Heart Association Established Investigator Award.