Medicare's Kidney Care Choices Models: Participation and Nephrology Care Practice Reforms

Medicare is the dominant payer for the >800,000 US patients with end-stage kidney disease (ESKD). These patients have poor outcomes and high medical spending, and there is wide variation in the quality and value of care across communities. Medicare is increasingly using novel payment models to contain medical care spending and improve care quality, including for ESKD. Starting in 2022, nephrology practices could choose voluntarily to participate in one of Medicare’s 4 Kidney Care Choices payment models; participants would bear financial risk for the medical costs and quality of care for their attributed patients with ESKD or chronic kidney disease stage 4 or 5. As of 2024, 123 provider groups were participating in a Kidney Care Choices model, representing >2,000 practices and ~2,700 nephrologists who care for an estimated >115,000 US patients with ESKD (>15%). Evidence on these models’ precursor, the Comprehensive ESRD Care Initiative (CEC)—including key evidence prepared by the proposed study team—showed that smaller (vs. larger) practices were less likely to participate in CEC, and the mortality and medical spending outcomes of CEC-participating practices’ attributed patients tended to be improved most in high socioeconomic-status communities. Because Kidney Care Choices includes several novel provisions (e.g., emphasizing ESKD prevention and transplant access), it is unclear i) how nephrology practices are deciding whether to participate in Kidney Care Choices and the roles of physician, practice, community, and policy-level factors in these decisions, and ii) how participating practices are reforming care models to reduce medical spending and improve quality. The proposed R03’s research objective is to examine practices’ participation decisions and practice reforms under Kidney Care Choices through a rigorous qualitative study. Leveraging PI Wilk’s strong training and applied practice in qualitative methods under his K01 Award (DK128384), we will conduct ~24 in-depth interviews with nephrology practice leaders to learn their perspectives on these topics. Aim 1 will examine how multi-level factors affect provider decisions about participating (or not) in Kidney Care Choices through in-depth interviews with nephrologists and practice managers, including model participants and non-participants. Aim 2 will explore how providers are approaching changing their care practices to improve financial performance and quality under Kidney Care Choices through in-depth interviews with model-participating nephrologists and practice managers. Thematic analyses of our rich interview data will yield valuable evidence on nephrology practices’ decisions to participate (or not) in Kidney Care Choices and how they are innovating in their care practices under one of Medicare’s largest payment reforms in specialty care. Our findings will guide future R01-level studies evaluating the health and health care impacts of novel payment reforms and practice leaders’ strategies for implementing care practice reforms intended to achieve system-wide goals of reducing health care spending and improving care quality for patients with chronic illness.