Dialysis Clinic, Inc. • Largest non-profit dialysis provider in the U.S. • Founded in 1971 (45 yrs ago) • Serving over 18,000 patients with kidney disease � Over 3,500 patients with CKD � Over 15,000 patients on dialysis • In more than 230 clinics • Across 28 states 1
Dialysis Clinic, Inc. • Founded DCI Donor Services • Operates three organ procurement organizations • Across TN, NM, and CA • 546 people received a kidney transplant in Lacey Wood: Heart Transplant Recipient 2015
DCI/Reach Is A Kidney Health Provider •We don’t want you to be on dialysis. Delay Dialysis •We will do everything we can to keep you off dialysis. Quality •If you need dialysis, you should receive quality dialysis care. Dialysis •If you need dialysis, we will work with you to help you Choices get a transplant or the best treatment possible. •We want you to be free from dialysis if possible.
ESRD Seamless Care Organization (ESCO) Started October 1, 2015: Submitted Applications For � 13 ESCOs Three More ESCOs: � Fresenius – 6 ESCOs � Heart of America Kidney Care Alliance (Missouri) � DCI – 3 ESCOs � Independence Kidney Care � DaVita – 3 ESCOs Alliance (Western PA) � Rogosin – 1 ESCO � Flint River Kidney Care Alliance (Albany and Columbus, GA) • DCI cares for 4% of patients on dialysis in the US, is responsible for 23% of the ESCOs
We Have A Seat At The Table As CMS Plans Changes in Kidney Care “When CMS is changing the rules, you want a seat at the table. If you don’t have a seat at the table, you may be on the menu.” * This statement does not reflect the view of CMS or CMMI 5
Plan To Improve Care For Patients with Kidney Disease 1. Increase CKD Care Coordination 2. Decrease hospitalization 3. Increase home dialysis 4. Decrease catheters 5. Improve care for end of life 6
Claims Data Analysis Hospital Admissions PPPY Music City Kidney Care Alliance 4.50 DCI analysis. Results 4.00 preliminary, 3.50 subject to change 3.00 2.50 All SNF and Rehab 2.00 Acute ER and Observation 1.50 1.00 0.50 0.00 7 Confidential
Claims Data Analysis Acute Days PPPY Music City Kidney Care Alliance 18.00 DCI analysis. Results 16.00 15.72 preliminary, 14.00 14.05 13.73 subject to 13.02 change 12.00 11.81 11.26 11.41 11.23 10.87 10.37 10.21 10.00 9.30 9.14 Acute Days per Pt Year 8.46 8.00 8.07 7.92 7.55 Linear (Acute Days per Pt Year) 6.00 4.00 2.00 0.00 Confidential 8
Improved Care For Patients With Chronic Kidney Disease • • DCI is following 3,500 patients in 29 Primary goal of Reach Kidney Care is different locations to make it less likely that a patient • needs dialysis One-on-one, in person care coordination • � First visit up to 1 ½ hours Additional Goals: � Improve care for patients at all • Ideally located in physician’s office stages of kidney disease • Have built CKD specific EMR � For those who progress to next • Progress note to physicians after each step in care, empower patients to visit make best choice for therapy • Electronic patient outreach � Reach Kidney Care is in direct (RoundingWell) competition with our dialysis • Data Integration Platform business ∗ DCI is currently managing more than 550 patients with Stage 5 CKD, not on dialysis
MAC1 Cost of CKD Point prevalent distribution & annual costs of Medicare (fee-for-service) patients, age 65 & older, with diagnosed diabetes, CHF, & CKD, 2011. Source: USDRDS ADR 2013, Figure 7.1 (Volume 1)
Slide 10 MAC1 Need a line added along the lines of: "CKD is associated with other co-morbidities and their related costs" Martin A. Corry, 9/13/2015
Breakdown of Cost for Medicare 65+ with CKD and Other Comorbidities Cost of CKD by Comorbidity Cost of CKD by Stage ∗ • CKD 3: $23,680 per year Patient with CKD: $21,909 • ∗ CKD 4: $33,374 per year Patient with CKD, CHF: $34,715 • CKD 5: $36,147 per year ∗ Patient with CKD, DM, CHF: $38,230 • CKD 5 on Dialysis: $84,645 per year (Average cost of patient on Medicare: $10,854) � Save more than $4,000 for each month that push back start of dialysis Source: 2015 USRDS ADR, vol. 1, table 6.1, Source: 2013, 5% Medicare Claims data set
Chronic Kidney Disease Management For every 1 million Medicare patients… Chronic Kidney Disease (CKD) Overview Late Stage 3 14,750 patients ∗ GFR (glomerular filtration rate) is an estimate of CKD kidney function. A GFR of 50 essentially means that a patient has 50% of their kidney function. Early Stage 4 3,200 patients ∗ Effective CKD management can delay or even CKD prevent the need for dialysis. Late Stage 4 1,600 patients ∗ We estimate that optimal time to start CKD intervening is a GFR of 45 ( Late Stage 3 ) Stage 5 CKD, 1,400 patients ∗ Patients typically need to start dialysis at some not on dialysis point after GFR is < 15 � Most patients from our best program start at GFR 5- Total CKD 20,950 patients 10 ∗ Nationwide, 12.6% of patients start at GFR > 15 In addition, 359 patients transition (Stage 4) to next stage in care each year.
CKD Care Coordination Late Stage 3 (GFR 30-45) • Only 8.4% of patients with Stage 3 CKD know that they have CKD • Our goal is to raise patient awareness and work with patients to slow progression of kidney disease. � “You are half-way to the dialysis clinic. We would like to work with you to help you stay off dialysis.”
CKD Care Coordination Stage 3b How Can You Improve Your Health? � Diabetes � Hypertension � Smoking cessation � Weight loss � Exercise � Avoid NSAIDS
Pre-emptive Transplant We see transplant as the ideal therapy for someone at the transition in care • Currently only 2.6% of patients receive a pre-emptive transplant Remove Barriers To Transplant • Get patient on transplant waiting list when GFR < 20 instead of waiting until start of dialysis • Increase access to living donation � Implement Donor Exchange Program � Provide initial evaluation for altruistic donation
Increase Transplantation Nashville, TN Partnership with St. Thomas Health System • January – June 2013: � 1 kidney transplant • July 2013 – present: � 76 transplants
Medical Management Without Dialysis Spartanburg, SC • 100 patients with GFR < 20 • 24 patients have chosen medical management without dialysis
Delay Start Nationwide : � 12.6% of patients start dialysis with a GFR ≥ 15 � A total of 14,357 patients in 2013 Spartanburg, since 1/1/2014: � 101 patients started dialysis from our CKD program � ZERO patients started with a GFR > 15 � Most patients started GFR 5-10 If we could delay start by just 2 months for those patients who started with GFR ≥ 15, could save CMS more than $110 million per year.
Avoiding Hospitalization Before First Dialysis Treatment ∗ About 1/3 of patients ∗ 113,944 patients started currently receive their first dialysis in 2013 dialysis treatment as an ∗ Can avoid initial outpatient hospitalization for additional 33% (37,601) ∗ We are seeing that we can ∗ Cost of hospitalization: double that number to 2/3 � $25,000 of patients starting as an outpatient if we follow them closely before the Total Potential Savings Per transition in care Year : Over $900 million
Improve Start of Dialysis Spartanburg, SC 2015 How Patients Start Typical Start CKD Program Dialysis Home Dialysis 9.3% * 37% For In Center, 20% * 68% Permanent Access Avoid First 33% ** 67% Hospitalization * 2015 USRDS ADR ** Wong SPY, Kreuter W, O’Hare AM: Healthcare intensity at initiation of chronic dialysis among older adults. J Am Soc Nephrol 25:143–149, 2014.
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