The Evolving Nephrology Landscape: Treatment, Innovation, and Policy
Key Takeaways
- The Kidney Care Choices (KCC) model expanded value-based kidney care beyond dialysis to include upstream chronic kidney disease (CKD) management and kidney transplantation, encouraging a more integrated, patient-centered approach across the full continuum of care.
- Health system leaders should focus on de-siloing care and investing in early CKD intervention. Preventing or delaying progression to kidney failure can improve patient quality of life while reducing reliance on costly treatments such as dialysis and transplantation.
- Although newer therapies such as SGLT2 inhibitors and GLP-1 receptor agonists carry upfront costs, their potential to slow CKD progression may generate long-term clinical and economic benefits. Value-based programs should evaluate these treatments through a long-term lens that considers patient outcomes, total cost of care, and care continuity.
In this interview, Suzanne Watnick, MD, discusses the lessons health system leaders can draw from the Kidney Care Choices (KCC) model as they develop value-based kidney care programs. She highlights the importance of managing chronic kidney disease across the full continuum of care—from early intervention to dialysis and transplantation—and explains how upstream investments in prevention and disease-modifying therapies can improve patient outcomes while reducing long-term healthcare costs.
Suzanne Watnick, MD: I'm Suzanne Watnick. I'm a card-carrying nephrologist, and I'm a faculty member at the University of Washington. I see patients at the Seattle VA Medical Center, I currently hold the American Society of Nephrology (ASN) Health Policy Scholar chair position, which I've held since 2024. I'm also the chair of our Policy and Advocacy Committee at the ASN.
One other aspect of my experience that may be relevant for this interview is that I served as chief medical officer at Northwest Kidney Centers from 2017 through 2023. During that time, I served as the president of our End-Stage Renal Disease (ESRD) Seamless Care Organization, which was the first of the value-based care entities that were specifically kidney related. This role provided a lot of experience for value-based care in nephrology.
What key takeaways should health system leaders draw from the Kidney Care Choices model when designing value-based kidney care programs?
Dr Watnick: The Kidney Care Choices (KCC) models were voluntary value-based care models that were begun by the Center for Medicare & Medicaid Innovation almost as a 2.0 version after the initial ESRD Seamless Care Organization or ESCO version of value-based care. There were 2 parts: One was specifically oriented toward nephrologists, the kidney care first model. Although a number of groups did join that model, it has been retired since then. What has remained are the other KCC models, the CKCC, the comprehensive kidney care value-based care voluntary group, which was an evolution from the prior value-based care entity, the ESCO, because it included not only dialysis patients, but also upstream care with CKD for patients. It also has a bonus for aiming to provide the best treatment for people with end-stage kidney failure if they're interested in it, which is kidney transplantation.
One key takeaway for health care leaders from the KCC is the de-siloing of care, which many of them are aiming to do. We're trying to think about the overall care environment for people with kidney diseases as opposed to only focusing on one part.
In terms of the value-based care equation, where you're trying to improve quality and decrease costs, you need to think about the entire patient care journey as opposed to only one portion of it. For example, if you can provide better care upstream before somebody requires dialysis or transplant, that is going to be cost savings, first of all, for the system.
But maybe even prior to the first of all, it also is beneficial in terms of quality of life for the patient who won't have to be on dialysis, which is really a part-time job that nobody signs up for. A kidney transplant is another great option for people with end-stage kidney, but it’s a big burden in terms of medications and healthcare interactions. So, it's better to avoid end-stage kidney failure.
One of the main goals of the KCC model is to provide care for a patient upstream to avoid the negative consequence if you cannot slow down progression. When you're talking about long-term value of emerging combination therapies for chronic kidney disease, yeah, they're high upfront costs. And yes, there are delayed returns, but what are you as a system health leader thinking about in terms of your patient's longevity?
I like thinking about the long term because all of us have to think about our overall life trajectory. If chronic kidney disease can be slowed down with expensive medications up front, it will be a lot less expensive to the health care system to avoid dialysis, which is extremely expensive. Another option is kidney transplantation, which is not as expensive as dialysis year over year, but still much more expensive than caring for somebody upstream with chronic kidney disease.
We're talking about using medications that are becoming less expensive. These include drugs to slow down CKD progression—SGLT2 inhibitor classes of medications in GLP-1 agonists, for example. Other mainstays such as RAS inhibition, renin-aldosterone angiotensin system inhibitors— losartan, lisinopril, just to name generic names of medications—have also been proven to slow things down. Some of the newer medications like SGLT2 inhibitors and GLP-1 agonists probably hold even more promise and a greater chance to slow things down. And SGLT2 inhibitors will be coming off patent and becoming less expensive in the very near future. The benefits the patients in terms of their overall care, their quality of life, and the overall treatment expense. Not only will the health care system benefit financially, but the lower costs will also benefit patients’ pocketbooks because they won't have co-pays, for example, to pay for these expensive therapies if the disease can be slowed down.
It’s important for people to make the business case for their health care system by looking at the expense of the medication and understanding what the price tag will be for that vs the longer-term therapies, expecting that the individual will be within that health care system for a number of years. Because if you predict that somebody is only going to be in your system for 1 year or 2, why would you pay for upstream care? Although it does improve the patient's quality of life, trying to keep individuals within your system is probably a better way of caring for them.
