Visioning and designing better kidney care
Insights from the OptumLabs Research & Translation Forum
The importance of improving kidney health
Chronic kidney disease (CKD), including end-stage renal disease, have emerged as national priorities with 37M* U.S. adults estimated to have CKD and most are undiagnosed. We can reimagine kidney care with new approaches to reduce the high cost and burden of dialysis.
Improving care for patients with late-stage kidney disease involves better access to transplants and home-based dialysis. Also important is identifying people with CKD earlier and providing advanced care management programs that can slow disease progression.
How can we mobilize to do this and take better care of patients with CKD?
Focus on the continuum of care
Learn more about how we can identify at-risk populations, facilitate transplantation and take action within primary care settings to improve kidney care.
Speakers: Anil Chandraker, MD, Medical Director of Kidney and Pancreas Transplantation and Director of the Transplantation Center, Brigham and Women’s Hospital; Soma Saha, MD, MS, Vice President, Institute for Healthcare Improvement; moderated by Jon Friedman, MD, Chief Medical Officer, Optum Medical Benefits Management
- In the Chinese calendar, 2019 is the year of the pig. 2020 is the year of the rat. I had to look that up, by the way. But I really think that going forward, this is going to be the year of the kidney. So, in a typical kidney program, we're dealing with stage four and stage five disease. And then stage five goes into ESRD and you go to dialysis, and that's just terrible. But what really got me really started in this whole concept of wanting to be Mr. Kidney or Dr. Kidney is that 43% of people that end up on dialysis have not seen a nephrologist within the last year prior to initiation of dialysis, and most of them haven't seen a nephrologist ever. I call those people lost souls. The best way to treat these people who have stage four and stage five disease is to get them referred for a preemptive living donor kidney transplant, never touching dialysis at all. That is the saving potentially of those lost souls, if we can identify them earlier. I'm very happy to say that we have embarked on a joint research project with NKF - and if you haven't met them, you should, they're really wonderful people - Optum Labs and our Kidney Resource Solutions at MBM, to figure out a way to earlier identify people with chronic kidney disease and get them into advanced care management programs that can steer them for preemptive living donor transplantation, slow the progression between stages four and five, get them set up for home modalities if they are not transplant candidates, whether it's home hemodialysis or nocturnal peritoneal dialysis, and do something that is effective in the management of these populations. It has been shown that the average population has about a 2.5% rate of preemptive living donor transplant. There's published literature that says aggressive care management can get that up to 12 to 24% and I am delighted to say within the MBM Kidney Program we have a 37% preemptive living donor transplant rate. That is people who have never touched dialysis or have never had to go through the pain, suffering and wasted ability to be employed. The other thing that really kind of got me wanting to be Dr. Kidney are the costs associated with kidney disease. If you are part of that 43% that shows up in the emergency room, actually it's probably higher than that, with a crash and burn uremic admission, that's $175,000. The cost of commercial hemodialysis per year is $280,000, mostly driven by the cost of dialysis and associated care. Very little of it is general medical care. It occurred to me that the best dialysis chair is an empty dialysis chair. And we really need to find ways to take better care of this population. If you can get a patient to have a preemptive kidney transplant, preemptive living donor kidney transplant, you save the healthcare system a half a million medical spend on that patient over the course of their lives, which is inclusive of the cost of the kidney transplant. The executive order that came out in July 10th of this year with President Trump and Secretary Azar of HHS, and the goal's is to really advance kidney health by getting people transplanted or home modalities over in-center hemodialysis, increase the number of available deceased donor kidneys for transplantation and redo a lot of the financial models, support living donors, potentially with replacement of lost wages, support the science of artificial kidneys. So on the panel, as was mentioned, we have Dr. Chandraker who is a longtime friend and colleague from the Brigham and the transplant world will discuss what it's gonna take to operationalize operationalization by the transplant community and what it's going to take to hopefully absorb this what I'd like to call deluge of patients that's going to come in because we are going to find ways to increase living donation. We're going to find ways to increase deceased donor donation. And Dr. Saha will talk about what can be done in the primary care community to improve the systems of care and to change what kind of management possibilities there are that can lead to help that inflow of patients earlier so we can get them into aggressive care management programs and increase that rate of preemptive living donation. Just one thing to remember: the best form of renal replacement therapy for someone with end stage renal disease is a kidney and not a machine. With that, I'll turn it over to Dr. Chandraker.
- So I asked Jon, how should I do this? He goes, "Well, you've got five minutes. "Think about it like Shark Tank." He didn't say that really. But yeah, I think as we started, with a personal anecdote, I wasn't going to say this, but I think it's very important to sort of really put this into context. I trained to be a nephrologist because I was interested in kidney disease, but when I was training to be a nephrologist, I really became interested in transplantation. You go and you see these patients on dialysis week after week, right? A week goes by, a month goes by, a few months go by, there's another empty chair. They all know where they're going. They all know that if you're on dialysis and say you're 65 and you're diabetic, your chances of making it five years on dialysis are only 50%. So this is a really significant serious disease. If you have end-stage kidney disease, your cardiovascular risk factors are 20-fold. That's in the general population. So this is really sort of a underestimated disease in many ways. But when we go back to kidney disease, I want to start firstly by talking about this as a whole, before we talk about transplantation because I think if you really are going to solve this problem, you have to look at this as a continuum. We've already heard large numbers of the number of people who affected, but it's estimated around 14% of the population are diagnosed with chronic kidney disease. That costs Medicare about $31 billion a year or 7% of their budget annually. There are about 500,000 patients on dialysis currently, about 200,000 patients who have been transplanted. The numbers are staggering and what is really driving this? What is driving this epidemic of kidney disease? Well, we've heard about diabetes. Diabetes certainly is playing a role. It's the most common form of kidney failure in this country, but so is aging. Aging per se is also a big driver of kidney disease. If we lived to be 120 we'd all have kidney failure because your kidneys don't regenerate. So every time there's a hit to the kidneys, you risk developing chronic kidney disease later on in life. Hypertension, hypertension is caused by kidney disease, but it also causes kidney disease and so the epidemic of hypertension related to obesity is also playing a role in the progression of kidney disease. So we think about kidney disease, somebody once told me that when you're giving a talk say things in threes, so I'm going to say things in threes today. So detection and prevention of kidney diseases is very important. People have talked about the risk, the risk-benefit ratio of detection of kidney disease and is it really cost effective? That's been argued about for years. Certainly there are strategies that would increase the targeting of at-risk populations. African Americans have a 3.5 time higher risk of kidney disease then Caucasians. Hispanics have a 1.5 times higher risk. Native Americans have a much higher risk of kidney disease. South Asians have a high risk of diabetes and hence kidney disease, so if you target your screening you can probably pick up a more targeted population where you can detect kidney disease and thereby prevent it. You have to work on progression. One of the issues that kidney disease, as a professional that I noticed and also from my personal experience, my father had kidney disease, and one of the things that you notice about this is that as a patient, if you have kidney disease and your kidney disease is progressing, you often see multiple different nephrologists. You'll see one at referral. If you are diagnosed with some form of kidney disease then maybe they'll do the biopsy. You'll probably go back to your primary care physician. You may get referred back to somebody who's taking care of your chronic kidney disease. Then you'll go and see another doctor. If you get put onto dialysis then you need to be evaluated. You'll see another nephrologist for evaluation. You get transplanted, you'll see another transplant nephrologist for followup. Then the cycle begins again because kidney transplants don't last forever. So you may see five, six, seven different nephrologists in a lifetime. Then on top of that with people changing care plans and other things you may see multiple nephrologists. One of the biggest problems that we have in terms of kidney disease is this loss of information that occurs every time you change your provider. Particularly when you're trying to prevent the progression of a disease, it's very important that we try to minimize that as much as possible. Then lastly, as already been said by Jon and something I'm going to spend a few more minutes on is transplantation and end stage kidney disease and how do we increase the number of patients who get transplanted because it is really the best form of therapy for patients who have end-stage kidney disease. So in terms of dealing with transplantation, you have to think about this in three different ways. One is the regulations of transplantation and how those put up barriers in terms of patients getting transplanted. The second is the practice models of transplantation and the third is actually the research that is still required in order for us to optimize careful transplant recipients. So one of the things with regulations is that there are a number of perverse incentives that occur because transplantation has many, many stakeholders. You have transplant centers, you have the organ procurement organizations that actually will procure the deceased donor organs. You have the people who are paying for the care, you have the surgeons involved, you have the nephrologist involved, etc. So a lot of this is governed by regulations and transplant center metrics. So even if you increased the number of people that you're delivering to a transplant center, that is not going to increase your rates of transplantation necessarily. This is a very important point because I think a lot of the policy is based towards getting those people seen at transplant centers. Well, transplant centers are guided by their one-year transplant survival and if you fall below a certain percentage of one-year graph survival, you are under regulation and your program may be suspended. So what that means is that transplant centers don't necessarily have to transplant. There's no penalty for you not to take a patient and put them on a wait list. Even if they're on the wait list, there's no penalty if you don't transplant that patient. So this has to be really fixed. One of the issues is that we discard 20 to 25% of all deceased donor kidneys. Why? Often because the quality of those organs is perceived not to be high enough to have a longterm outcome, good outcomes, and therefore why take that risk if you're a center? There's no incentive in that, particularly as we have so many patients who are waiting for transplantation, right? In Massachusetts, it'll take you five to six years on the wait list to get a deceased donor transplant. In California is close to 10 years. So it's different in different parts of the country, but the point is that centers don't have a shortage of patients and they can transplant. So this is something that we have to fix and when we look at these regulations, we have to make sure that they go in sync. A lot of this is really based on the regulations that have come about over the number of years and have really sort of molded the way that we have transplantation done in this country and there isn't really time to go into this, but one of the things that has to really be considered is that whatever regulations are put in place to increase the number of transplants or to increase the incentives for detecting patients with kidney disease or treatment of chronic kidney disease, there has to be a process of review. So this is just one example of what has happened in transplantation. What you see here is a black line, which is the one year graph survival. So that means that the improvement in one-year transplant survival has been very significant over the last 20 to 30 years, such that around 95% of people who get transplanted will survive one year. The problem with that is that it means that the difference between transplant centers is getting smaller and smaller. So if you're penalizing the bottom third of transplant centers, guess what? There's no real difference. So we're spending a lot of time regulating these centers and deciding which centers need to be penalized when there's really no difference between them. That has so many other effects that really reduce the potential of transplantation. The one-year outcomes are taken up by providers of insurance because they look at these and decide which are centers of excellence. They're taken up by the FDA indirectly because the FDA will say if you want to have a new drug to treat transplantation, you've got to be able to show that there's a difference in transplant outcomes. Well, guess what? If your outcomes are 95% at one year, it's very difficult to show that there's a difference. So these sorts of regulations, while well-intended, may have been excellent when they were first put in place, need to have the ability to be modified as time goes on. I'm gonna stop there because I want to give time for the last speaker, thank you.
- I'm Soma and I am a primary care doctor. That means that my job, actually I'm a med peds primary care doctor. That means I see people before they're born and I take care of them until after they pass away and often take care of multiple generations of family. Practiced in the safety net for a number of years and as I did that, began to see the same patterns happen over and over in the same places in generations. So 100 Million Lives was born as an effort to begin to say, wait a minute, we're making progress, but actually there seems to be a tanker full of gasoline going into a fire even as we're mobilizing as a bucket brigade trying to put out the fire. I'm gonna share a little bit with you about that story and some of what we've learned as we've formed a network of 1,800 partners reaching over 500 million people in 30 countries, actually improve the lives as partners of over 700 million people and figured out what it took to begin to think differently about what it takes to improve population health outcomes at scale. So I always say this is a very simple graphic. You need to think across the entire continuum of how do you prevent root causes of disease? That needs to happen in home, community, public health context. How do you manage disease proactively and support people in lifestyle change, whether it's kidney disease or anything else in primary care, mental health community, and how do you minimize the impact of disease seamlessly? So I had the great job over the last five years of getting to travel all around the world to see amazing examples in all of these contexts. Going to see in Jonkoping, Sweden, the very first self-dialysis center where patients administer their own dialysis with a key pad. Came in at five in the morning, exercise while they were doing dialysis and got out and actually lived their lives, worked, actually managed to continue to have their hope in life back. That was one of the most inspiring things that I ever had a chance to see. As we see the data emerge, as many, many people begin to say, "How do we actually think differently "about getting people to transplant faster "so they can have their lives back?" One of the things that emerged in all of the places where we were beginning to see breakthroughs, people were orienting not just to how do we treat a clinical indicator, but how do we actually help people have their lives back? I will tell you, that's one of the things we've learned is an incredibly orienting thing to do if you want to improve population health outcomes and cost. In the middle bar, we learned a ton about how to not only treat kidney disease but many other chronic health conditions. I'll share with you some of the stories of that, but I'll also share with you some of what we've learned about what it looks like to do that in a way that we can really get serious about prevention along the way. So at Cambridge Health Alliance, which is just across the river, safety net system that takes care of about 130,000 people, 82% of whom are on Medicaid or Medicare, we were able to see some real differences, some real changes in actual outcomes for just one chronic illness that leads to poor kidney disease, diabetes, which you've heard a lot from today. We didn't yet have the diabetes prevention program. I wish we did at the time, but we were able to by really organizing primary care in a way that it made a whole team using EMRs to really move how care happened in a reliable way. Leveraging the power of patients, group visits, pure, we did everything, integrated mental health and we were able to see a 36% reduction in all cause hospitalizations for all people with diabetes. This was an incredible accomplishment in a safety net population. I'll tell you that that trend has continued. It's at 40%. Great, right? Except that little, I kept going, "Wait, why are the number "of hospitalizations not decreasing?" They're actually about stable. So I began plotting out what was happening in terms of the population developing prediabetes and diabetes at the same time. Basically that number quadrupled. Now, a third of that was because of Massachusetts Healthcare Reform, but that wasn't the whole story. As I began digging, and you've heard the numbers of 86 million people with prediabetes and diabetes. One in three Americans, predicted to be one in two, spending 322 billion now, 520 billion by 2020 is I think their current estimate, that that money will go out the door because we have a production system for chronic disease and diabetes in place. I want to suggest to you that one of the simplest risk factors we can begin to look at is place, that in your risk models, this one field that's in just about every EMR that's there, the ZIP code, ought to become part of our risk prediction systems of who's likely to have a poor outcome. Not just for a kidney disease, but for any chronic illness. Because in every community across the country, we began to see maps like this when we began mapping outcomes data. We now know that two kids born two miles apart right here in Boston will have 10, up to a 10 to 30 years if you go farther along the subway lines in terms of how long they'll live predicted at birth. It turns out most people somehow think that they're in bad neighborhoods and there are going to die of gunshot wounds. That's not true. They're dying of heart disease, diabetes, kidney disease. They are high-risk, high-cost patients. In fact, these pictures where on the left-hand side is of economic hardship. On the right-hand side is childhood obesity. If you flip that up another 30 years, that'll be premature diabetes. Flip that another 10 to 20 years, that'll be the development of chronic diabetes and chronic kidney disease. Flip that another 10 years you'll see premature mortality. There is a production system in place that relates to legacies of structural racism, etc. that we don't have time to go into, but I want to invite you today to think about the health and wellbeing of people, places, and equity as fundamentally interconnected. We think now that this is actually biologic, that growing up in conditions of toxic stress creates allopathic stress. It leads to some of those racial and ethnicity differences that are described where, as people develop allostatic stress, which turns out to come from the experience of living under challenging circumstances, it actually raises their blood pressure. It actually prematurely ages them. Even the perception of everyday discrimination four or more times a year seems to take five years off your life span. So if we know this, we can begin to say how do we act differently? So the first is to get focused. We talked a little bit earlier about focusing on who's at most risks. I would encourage us to not just think of those as individual factors, but to hone in on ZIP code as a really good way of focusing in on where resources should be. If you're going to focus on investments, think about investing in places and resources in places and in populations that are from places that have poor outcomes. Anchor strategies are a great example for doing that. Some of that might be investing in those Lives that might've been closing in those places that could provide something like a diabetes prevention program. But another opportunity is who we hire and where we put our investment dollars in the healthcare arena. I think we're really under utilizing our resources there. The third is to look for the assets in those places. So it turns out someone would come and see me, and people really liked me as a doctor, people would still see me four times a year at most, right? For 15 minutes, an hour while managing their diabetes for 5,000 hours. Over and over in communities we saw that faith communities or places people went every week, that barbershop and beauty salons, those could be the places for early diagnosis. I think part of what we need to do is begin to think differently about who our and where our partners and assets could be as it relates to place. So I just thank you so much for being willing to think a little upstream with me today.
