This is Jeffrey Berns, editor-in-chief of Medscape Nephrology, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. The chair of the Senate Finance Committee, Orrin Hatch of Utah, and its ranking member, Ron Wyden of Oregon, recently announced the formation of a working group,[1] to be chaired by Johnny Isakson [R-Georgia] and Mark Warner [D-Virginia], to look into improving the care of patients covered by Medicare who have chronic conditions, particularly multiple chronic conditions.
The intent of this working group is to figure out ways to streamline the care of patients with multiple chronic medical conditions and create incentives for providing the appropriate level of care; increase care coordination among providers involved in the care of these patients; decrease costs to Medicare; and improve outcomes, care transitions, and the overall delivery of high-quality care to these patients.
Obviously, patients who have chronic kidney disease (CKD) have a chronic condition, and they often have multiple other chronic conditions such as high blood pressure, heart failure, and diabetes, so they nicely fall into the interest area of this working group. Several nephrology organizations have made proposals to this working group, including the National Kidney Foundation (NKF), of which I am president.
The NKF had several recommendations:
One was that the Secretary of Health and Human Services develop a bundled-payment model and quality metrics to incentivize earlier detection and better management of patients with CKD by primary care providers (PCPs).
Another suggestion was that the Secretary develop a capitated payment model for nephrologists to manage patients with stage 4 CKD and to identify and develop quality metrics that can be tied to reimbursement for nephrologists providing care to these patients.
A third recommendation was that there be development and testing of a payment model for comanagement of patients with advanced CKD who don't have end-stage renal disease that would involve both PCPs and nephrologists.
Finally, their fourth recommendation was that there be a reduction, if not elimination, of copayments and coinsurance that present barriers to patients for such services as physician care and dietician services, and that medical nutrition services and CKD education services be provided more broadly, including through telehealth.
I thought these were all great recommendations. I am sure that there are other great recommendations from other nephrology and kidney patient care organizations.
These recommendations got me thinking about the potential role for a nephrologist as the PCP for patients with advanced or late-stage CKD, such as those in stages 4 and 5. We usually share the care of patients with their PCPs, but maybe we should take on a more primary role for these patients, particularly in areas where PCPs are not as readily available, or when they may not be interested in providing late-stage CKD care.
We would assume management of immunizations (making sure that patients receive hepatitis B immunization, for example), their comorbidities (heart failure, diabetes, etc), and their transitions along the CKD spectrum as patients move from stage 4 to stage 5 CKD. We would make decisions about dialysis, transplantation, access—or even conservative care and no dialysis—as well as manage the complications of CKD as the PCP rather than as a participant in care. This would require retraining on the part of practicing nephrologists and some new components of training for fellows, whom we don't really train now to be PCPs.
I know that there has been talk about this in the past and that there is some debate about the role of PCPs for dialysis patients. Perhaps we should be thinking about that role for patients with stage 4 or 5 CKD as well.
Medscape Nephrology © 2015 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Should Nephrologists Be PCPs to Late-Stage CKD Patients? - Medscape - Aug 07, 2015.
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