Reshaping Dialysis Care: How New Payment Models Focus on Quality and Outcomes

Announcer:
Welcome to Clinician’s Roundtable on ReachMD. On this episode, we’ll hear from Dr. Mallika Mendu, who’s an Associate Professor of Medicine at Harvard Medical School, Chair of the American Society of Nephrology's Quality Committee, and Chief Population Health Officer for Mass General Brigham. She’ll be discussing her presentation at the American Society of Nephrology’s 2025 Kidney Week conference that examined how payment systems currently approach dialysis and chronic kidney disease care and how nephrologists can advocate for reforms. Let’s hear from Dr. Mendu now.  

Dr. Mendu:
Traditionally, in nephrology, as it relates to dialysis and chronic kidney disease care, we are very much for our patients who have Medicare and other types of insurance, like commercial insurance or even Medicaid, paid based on how often we see patients. Dialysis is a little bit different in that we see patients in dialysis centers often if they’re on hemodialysis, or for patients on home dialysis, we often see them once a month. And the dialysis organizations get a fixed cost or sum from Medicare and CMS to be able to provide care to our dialysis patients. it’s a bit different in that it is not based as much on how many visits we’re having with the patient. And so historically, we have been very much focused on getting patients in, providing them with the right care, but less on looking at their quality and clinical outcomes.

And what has happened more recently—I’d say really in the last 10 years, but particularly with the announcement of the Advancing American Kidney Health Initiative in 2019 by the Trump administration, which was an executive order to focus on public policy related to kidney disease—there was a shift by announcing that there would be payment models created to truly focus on improving a couple of things: home dialysis utilization, transplantation, and overall thinking more about clinical outcomes and quality.

And so given that shift over the last few years—particularly amongst those providers, health systems, and dialysis organizations participating in these new payment models that are looking at outcomes, that are looking at costs, and really focusing on quality—now the payment structure for those individuals is based on looking at key metrics and performance on those metrics. And so what health systems, and provider groups, and dialysis organizations have been asked to do and are doing is now thinking about the healthcare ecosystem and how we optimize care throughout that ecosystem. So as an example, there have been providers participating in the Kidney Care First model or Kidney Care Choices, and in that model, we are measured on optimal starts—that is, whether or not a patient gets transitioned to dialysis as an outpatient or gets on home dialysis. And the results from that program were just published and showed that, in fact, the model is working and that we are seeing an impact on optimal starts and seeing more patients of those providers participating in the model getting optimal start care.

I think we really have to ensure that there’s an emphasis on investment. That there’s a recognition that in order to move from position A, which is where we have been operating in a fee-for-service, volume-based model, to position B, where we are hyper-focused on clinical outcomes and quality, that the structures need to change. And so for the structures to change, there needs to be investment, and that’s what I worry about. Recently, as the positive data was released about the Kidney Care Choices model, the government announced that they were going to cut back on the incentives to providers, and that concerns me because ultimately, what the incentives are really driving is investment in resources. Those are the types of payments that are going to help a practice invest in a coordinator, help a practice invest in a nurse or a social worker to help bridge getting from position A to position B. And so aligning the payments with how care is delivered is critical, but also recognizing the realities on the ground and what our practices are facing as healthcare is becoming increasingly difficult with respect to reimbursement and operational practice. 

Announcer:
That was Dr. Mallika Mendu sharing key takeaways from her presentation at the 2025 Kidney Week conference. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!