Chronic kidney disease (CKD) imposes a large burden on patients and families and the US healthcare system as well. Approximately one out of seven US adults has CKD. In 2019, Medicare fee-for-service beneficiaries with CKD had an all-cause mortality being twice as high as that of those without CKD and accounted for one-fifth of the annual total Medicare fee-for-service spending or $87 billion.
Pioneered by Dialysis Clinic, Inc.––a Nashville-based nonprofit––through its subsidiary REACH Kidney Care, CKD management has been greatly improved, particularly in four key performance areas: preemptive kidney transplant, home dialysis, use of permanent access at hemodialysis initiation, and avoidance of inpatient dialysis initiation.
In 2018, we published a simulation study in the Journal of the American Society of Nephrology to quantify potential savings if an innovative kidney care model similar to REACH Kidney Care had been implemented nationwide. We used a set of simulation parameters primarily derived from the REACH Kidney Care model and found that improving CKD management for Stages 3 to 5 patients would have had generated an annual savings of $1.4 billion in the year 2015 (2016 US dollars).
In the last several years, innovative kidney care models have been adopted by additional private enterprises, e.g., Cricket Health, Monogram Health, Somatus, and Strive Health. As illustrated in the figure, in each of the key performance areas, all these companies have exceeded our expectations reflected in the “Parameters in Our 2018 Simulation.” For example, REACH Kidney Care reported a preemptive kidney transplant rate of 7% among incident end-stage renal disease (ESRD) patients, higher than the 6% used in the simulation under a hypothetical program.
Similarly, we assumed 43% of incident ESRD patients had a permanent access at dialysis initiation––a fistula or graft––but among the three companies reporting such data, all have achieved a higher rate, ranging from 45% at Monogram Health to 71% at REACH Kidney Care, whereas the 2019 national average was only 18%.
Over three-quarters of patients transitioning from CKD to ESRD in Cricket Health, REACH Kidney Care, and Strive Health initiate the dialysis in an outpatient setting and thus avoid an unplanned and expensive inpatient dialysis initiation.
Finally, home dialysis initiation rates are also much higher (ranging from 28% to 63%) than what we assumed (26%) for a hypothetical enhanced CKD management program.
All the data point to a direction that innovative kidney care programs are generating tremendous savings for patients as well as for payers, an amount likely larger than our previous estimate of $1.4 billion per year.
Of course, our analyses are based on self-reported data from these companies, and formal rigorous evaluative research is urgently needed to confirm our observation.