Voices of MCMS:
Using Data to Improve Kidney Care
A conversation with Mandeep M. Sahani, MD, of Desert Kidney Associates.
MCMS: This is a broad question but what does big data mean to you?
Dr. Sahani: I don't know what big data means. I can tell you what small data means to me. Nephrology, by and large, is a data-driven specialty. If a patient comes to my clinic, the basis of our diagnosis, of letting them know whether they have any kidney issues, is based on data. Data defines our clinical approach to that patient because either you have chronic kidney disease, or you don't. It's a little different and more objective for us as a specialty as compared to, say, cardiology.
MCMS: Nephrology, you’re saying, is more accurate in terms of understanding what is within or without the boundaries of a normal level for diagnosis and treatment?
Dr. Sahani: Our data are more numerical data, as opposed to qualitative data. I could have chest pain coming from either my heart or from a musculoskeletal origin, whereas here we do a blood test, and we discover a variation in the patient’s creatinine, for example, and then we conclude that there is chronic kidney disease or an acute kidney disease. For us, everything evolves around that data piece to the point that we could potentially come to a diagnosis even before we walk into the patient’s room. We already have a good idea of the conversation we're going to have with the patient.
MCMS: How often do you draw labs for monitoring a patient and where does the information go? Also, describe the two-way communication with patients in terms of sharing data to keep your team and the patient informed.
Dr. Sahani: That would depend upon the stage of the chronic kidney disease, which is five stages. For stage 1, we'd want to see the patient and get the data maybe once or twice a year. For stage two to three, maybe every six months or so, and then stage 4 is every quarter. Stage five is every month and then once you're on dialysis, it's either once a month or twice. Once we ingest that data, we compare it to the trend and previous times we saw the patient or the data available to the patient’s primary care provider or other specialists. There are certain calculations to establish at what rate is that individual going to progress towards worsening CKD, perhaps requiring dialysis or a kidney transplant. That's how data helps us to forecast and risk stratify. It could be his other disease morbidities that are either causing or influencing his chronic disease like diabetes, so we examine hemoglobin A1C, how sugars are controlled, and blood pressure. Aggregating that data, along with the kidney specific data about the patient’s creatinine and urine, you can predict what the trajectory is going to be. Is it going to be flat or go downward? Do we have to intervene at a particular point? When do we educate him about kidney replacement therapy, which is transplants or dialysis? Once you choose dialysis, what kind of modality is best suited for that patient, either at home or in center? One very important point that you rightfully asked is how do we educate our patients about empowering them and comprehending what that data means for them in their continuum of the disease progression.
MCMS: Do you find that most patients can easily understand it?
Dr. Sahani: That's up to us how we break it down to them. Certain patients who get it right away. If there are patients who are tracking their other parameters of health, like number of steps, heart rate, blood pressure. Those patients get it much faster than the patients who are naïve in this regard. But then it's up to us. We're accountable to get them up to speed on having them recognize that data is very important, especially as relates to the kidney disease.
MCMS: And you probably have some patients who have no idea how to log into a patient portal to access their information and, for others, it’s second nature.
Dr. Sahani: You'd be surprised. The demographic that we treat is about 65. Most of our patients are Medicare patients. And we thought they wouldn’t be savvy enough to send messages back and forth on a text message but, no, they are savvy enough to learn how to and to get into their portal to see what their labs are. Some even have them on their handheld.
MCMS: Do you think the data matters more under the value-based care model for reimbursement? How do you make sense of all that information to know how it's helping the practice as a whole?
Dr. Sahani: If there's a cohort of maybe 1,000 patients, it’s good to know where that population is in relation to their disease progression for CKD and then risk stratify those patients based upon how many CKD ones, twos, threes, fours and fives are there in the population and have a targeted intervention for that particular disease state. Then you empanel that to the respective physician who's taking care of that subset of maybe 100 or 150 patients. You can use that data to create a scorecard for that physician. But you have to democratize the approach and make sure to factor the variability if you are presenting it to a physician, because there will be 1,000 questions.
MCMS: What impacts have you seen so far?
Dr. Sahani: Well, we just started last year. We've done better towards the end of the year than we did towards the start of the year. The challenges were getting the right data for the right population and, in this particular instance, the data is given to us by CMS. We’re in a CMS demonstration project called the Comprehensive Kidney Care Contracting or CKCC, which takes in the patients who are at risk are CKD fours and fives and are dialysis patients. In the first year, completed last year, we had some challenge identifying those members, getting them to understand what this means for them and why we're doing these interventions. But towards the end of the year, we saw significant improvement in other metrics like how we measure one cohort versus another. When we see a transparency list between other such entries across the country, that's how we compare by big data.
MCMS: What would you say to a primary care physician about why to refer patients to your team? What’s the value added of the data and why it makes a difference?
Dr. Sahani: That's an excellent question. In the value-based care space, the PCPs are far ahead of us because they started with the ACOs. There were multiple iterations of the ACOs. For most of the specialists, that’s their high spend, for the ACO or DC. The sicker the patient is, the more spend for that patient. We can educate them about when to refer patients to us and, once patients are referred, manage and control the disease progression in conjunction with the PCP. The PCP in a fee-for-service model then realizes the savings at the back end at the end of every fiscal year. That's how we approach this partnership. If both such entities are CMS demonstration projects, it would be very nice if in the PCP's cohort, patients who progress to latter stages of CKD could move into our kidney care ACO, so that could offset their spend. They won't be liable to manage the sicker population. It would all shift to us. It won’t be counted on their end.
MCMS: Tell us about the Gold Kidney Health Plan? What is the value added to an individual patient and to the PCP?
Dr. Sahani: The Gold Kidney Health Plan is a C-SNP Medicare Advantage plan. C for chronic and SNP for special needs plan. Medicare allows the creation of C-SNP Medicare Advantage plans based upon certain disease criteria that you can choose. You can either club them together or you can take individual diagnosis criteria and create a health plan based upon that diagnosis, so only patients or members who have that diagnosis can enroll. We want to influence and help to treat chronic kidney disease patients because the spend on CKD and ESRD is upwards of $120-130 billion, which is still a fraction of the total healthcare spend, but nevertheless this disease state doesn't get as much attention as we nephrologists think it should. And the attention doesn't come from patients themselves. The attention doesn't come from health plans. Health plans are focused on educating, bringing on baby boomers every year. Every day, there's about 10,000 baby boomers that are Medicare eligible, so they are chasing that market. We’ve decided to take care of the more complex patients which are a subset of those patients and give them due attention and create a model of care that is designed specifically for that population. Where does CKD come from? If you move further upstream, it comes from diabetes, congestive heart failure, hypertension, and peripheral vascular disease. So, we move upstream. We've chosen a group 4 plan, which encompasses all of those diagnoses, plus end state renal disease. And when you come to end stage renal disease, the plan we've designed is an HMO POS plan, which means that patient can go see any provider in network or out of network as long as the provider is willing to see the patient. The plan will pay that provider. There are other things built in. We have a PERS button, which stands for personal emergency response system unit. If you need to reach a care coordinator, the patient presses a button, and they get somebody to talk to them. It's linked through LTE wireless communication, and they can communicate with them anytime. We provide transportation for dialysis patients. We've made it very easy for them to get access to care when they would not otherwise. The other thing that we're focusing on is to bring dialysis to a home and make it more customizable so they can fit it into their schedule as opposed to having a fixed time at a dialysis unit which may be 5 or 10 miles away.
MCMS: Leading to better patient adherence and care. We're here in Mesa and the largest growing population of anyone moving to Arizona is those who are over 55 or those over 65. In your view, where do you see the growth?
Dr. Sahani: Definitely in Maricopa County and Pima and Pinal. But our focus is also trying to bring nephrology services to rural markets in Arizona or outside of Arizona. I think that's where there's a terrific need. For example, at Globe, they have a dialysis unit in the community. But in the hospital, there was no dialysis available. Patients, if they were admitted for low acuity condition, pneumonia or cellulitis, we transferred 90 miles into the valley and so would their family. It's a deficit to the bottom line of the hospital and not productive. By creating a service line there, remotely providing nephrology services, we were able to create an inpatient dialysis program that benefits the hospital, benefits the community, benefits the patient tremendously. I think the rural market is where our focus should be.
MCMS: Dr. Sahani, thanks for your time.
Dr. Sahani: You’re welcome. Thank you.