RAND: Expanding access to specialists, coordination for kidney care could save $1B each year

Dialysis machine
Getting patients to a specialist before they need dialysis could save billions, according to a new study. (Getty/porpeller)

Providers looking to reduce the cost of kidney care should do so by getting patients to see a nephrologist sooner, according to a new report.

Researchers at RAND Corporation estimate that providing patients with coordinated chronic kidney disease care before they need dialysis could save the healthcare system more than $1.36 billion each year.

The majority (60%) of savings, according to the report, are from avoiding patients starting dialysis in the hospital where it is far costlier. Two-thirds of dialysis patients begin that care in the hospital, said Harry Liu, Ph.D., a senior policy researcher at RAND and the study’s lead author, so reducing that number would pay off significantly.

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Liu said that this intervention represents “low-hanging fruit” in the quest for cost savings.

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Of the estimated savings, $730 million would be in Medicare alone, according to the study. Liu said it’s also likely that the number would rise if estimates were expanded to patients who have an earlier-stage kidney disease.

There are a number of factors that can lead providers to send patients to a specialist later than might be optimal, Liu said. For one, it’s not easy to determine the ideal point for a referral until a patient clearly needs dialysis care, he said.

“It’s very hard to predict when the patient would actually need dialysis,” Liu said. “Some deteriorate faster than others, at which point the chronic care providers refer patients to the nephrologist.”

Financial incentives in fee-for-service care also play a role in this “complex” dynamic, he said. One way to address these incentives, Liu said, would be to create a bundled payment model for kidney care, which would push providers toward better coordination and lower-cost care.

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A nephrologist can also provide pre-dialysis renal replacement therapy at a lower cost but with equal quality to a hospital, Liu said. An episodic care model would also drive providers to make that referral sooner, he said.

In addition, Medicare and private payers could both reconsider their approach to chronic care management for kidney disease. Medicare does not currently cover renal disease under its chronic conditions special needs plans, Liu said. As these benefits are paid out on a per-patient basis, that could better align incentives for providers to improve coordination.

Private payers likely stand to benefit financially even more than Medicare, Liu said, as they’re typically charged higher rates for care. Slowing the progression of renal disease in their members could lead to significantly lower costs.