Exploring the Kidney Care Environment, Part III: Addressing Healthcare Disparities

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Tune into the third episode in the Avalere Health Essential Voice podcast miniseries focused on the evolving kidney care landscape. In the final segment, our Market Access and Policy experts take a deeper dive into disparities in kidney care and discuss how various groups are looking to address these gaps.
“Based on what we know of some of the existing gaps in access to and utilization of healthcare services, specifically dialysis services, these models provide opportunities for providers to reexamine the impact of social determinants of health on specific patient populations, and really leverage that information to redefine how they provide care.” Brigit Kyei-Baffour


Emily Belowich , Associate Principal, Market Access & Reimbursement

Emily Belowich supports clients across the healthcare system seeking to optimize payment and care-delivery strategies as they adapt their business models toward value-based environments.

Brigit Kyei-Baffour , Principal, Market Access & Reimbursement

Brigit Kyei-Baffour advises clients on issues related to market access, policy, and reimbursement strategies for digital health, diagnostic, medical device, and pharmaceutical companies.

This interview was originally published as a podcast. The audio is no longer available, but you can read the transcript below. For updates on our newly released content, visit our Insight Subscription page.

If you would like to watch the video version, please visit our video page.


Emily: Hello and welcome back to the third and final piece of our Kidney Care Outlook series. My name is Emily Belowich and I’m a Consultant in Avalere’s Market Access practice. I’m excited to be joined today by 2 of my colleagues, Grecia Marrufo, a Managing Director in our Policy practice, and Brigit Kyei-Baffour, an Associate Principal in our Market Access practice.

We spent the first 2 episodes doing a deeper dive into the kidney care stakeholder environment, providing a snapshot of the key players such as the large dialysis organizations and the specialty kidney care companies. We’ve also had an opportunity to highlight some of the significant policy reforms impacting the kidney space, such as the 21st Century Cures Act, and outlined some other important challenges and opportunities ahead for payers, manufacturers, and other stakeholder groups.

There’s one piece that we have not yet addressed head-on and that is disparities in kidney care. We know that racial, ethnic, and socio-economic disparities in chronic kidney disease have been documented for decades, but there has been little progress made in mitigating these challenges.

I want to turn to Grecia first. How is the CMS Innovation Center (CMMI) looking to address these gaps?

Grecia: Thank you so much for this important question, Emily. Advancing health equity has been and continues to be a cornerstone of the Biden administration, but as you mentioned, these disparities in kidney care have existed for years. We’re talking about disparities in quality of care, transplant recipients, and access to home dialysis.

CMMI has demonstrated its commitment to focusing on kidney health disparities in a few ways. Most notably, we saw a lot of movement in the rulemaking cycle for the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) rule. Last fall, CMS finalized various proposals that were introduced to further address health and socio-economic disparities in kidney care. We saw these changes in the ESRD Treatment Choices Model, also known as the ETC Model. This model includes incentives for participating dialysis facilities and managing clinicians to advance health equity, enabling access to alternatives to in-center dialysis for ESRD patients of lower socio-economic status.

CMS finalized its approach to the ETC model benchmarking and scoring methodology with the addition of the health equity incentive to the improvement scoring methodology. With the health equity incentive, ETC participants who demonstrate significant improvement in the home dialysis rate or transplant rate among their aligned beneficiaries who are dual eligible for Medicare and Medicaid, or who are low-income subsidy recipients, could earn additional improvement points.

Emily: Thank you so much for this intel, Grecia. It’s really exciting to hear about the work that CMS is doing to address these gaps.

Brigit, you focus most of your time at Avalere on the role of social determinants of health tied to healthcare. Can you help us make sense of some of this information? How can this translate to health system environments, and when can we expect to see some of the real effects of the new policies?

Brigit: Yeah, thanks, Emily. It’s a good question. This is a major milestone for CMS and it’s a great example of CMS making equity the centerpiece of one of their innovation models. It’s huge to see the Innovation Center looking to include more providers serving low- and moderate-income communities, racially diverse populations, and/or rural populations in their models.

Based on what we know of some of the existing gaps in access to and utilization of healthcare services, specifically dialysis services, these models provide opportunities for providers to reexamine the impact of social determinants of health on specific patient populations, and really leverage that information to redefine how they provide care. Now that the ETC model, which is a mandatory model, is underway, we can expect to see the impact of some of these changes as early as the end of 2022.

Emily: That’s great to hear. I’m excited to see the progress of some of these models and how they come into effect in healthcare systems and in some of the scoring and improvement methodology. I want to continue the conversation about health inequities in kidney care, but I’m also interested in hearing what’s at the forefront of professional societies and delve into what’s important to patients.

Grecia, can you tell me a bit about what is top of mind for professional societies in kidney care specific to addressing disparities?

Grecia: Absolutely. There are a couple of things to call attention to. The first one is related to the glomerular filtration rate (GFR). For those who may be unfamiliar, estimating this rate is done through a test that measures your kidney function and determines your state of kidney disease. If your estimated GFR number is low, your kidneys may not be working as well as they should. Individuals with low GFR are at an increased risk of having chronic kidney disease progress to kidney failure.

One of the things that is interesting about this rate calculation is that since 2009, it has been based on an equation that uses age, sex, race, and creatinine level to determine this number. In recent years, concerns have been raised that the use of race in estimating GFR could contribute to care inequities, especially in kidney disease. Black Americans are 4 times more likely than White Americans to have kidney failure, but at the same time are less likely to receive kidney transplant. So, there is a concern here about how the inclusion of race can affect care decisions.

The second piece is around closing the race and ethnicity gap in access to living donor kidney transplant. As it stands now, racial concordance is not required for living donation. Nevertheless, racial concordance in living donation is over 95%, and about 75% of living donors are White. As a result, there is a huge disparity in access to living donor kidney transplants, which are limited to begin with.

Emily: It’s so interesting, thank you for sharing. I know that these are 2 of many items that we’re seeing in advocacy for health equity in kidney care. Among the 2 pieces that you just mentioned, Grecia, we know that there’s a continued focus on increasing public investments in kidney health equity, extending Medigap to all ESRD beneficiaries, ensuring equitable access to home dialysis, among many other initiatives to address disparities. So, Brigit, what is Avalere doing to track these items? What else is happening on the horizon of social determinants of health and health equity in kidney care?

Brigit: There’s a lot that lies ahead. Avalere is doing a lot of work with our clients to try to analyze what this means in the world of kidney care service utilization. In fact, Avalere conducted an analysis last year that found gaps in access and outcomes of kidney care across patient race, ethnicity, and socio-economic factors. What this analysis really highlighted was that there’s a huge need for stakeholders ranging from dialysis organizations, nephrologists, payers, and life sciences companies to really take a collaborative approach toward advancing efforts to close the gaps in care by understanding the clinical and social needs of historically underserved patient populations, and using that information to remove barriers to access for treatments including drugs, devices, therapies, and other forms of care.

In addition, Avalere has also engaged with our clients to take a deeper look at the impact of social determinants of health on disparities in care by leveraging our internal data assets to better understand affordability and access barriers to care and what the impact of those barriers are on specific patient populations.

We also engage with stakeholders via primary research to better understand barriers faced by specific communities. We talk to payers, providers, health systems, and other key stakeholders to better understand what those barriers are and strategize on how to arrive at targeted solutions. As part of those engagements, we’ve done patient population mapping to better understand variations in treatment patterns and health outcomes, as well as look at the impact of some of those factors on ways to address treatment and ways to improve access to care.

These are just some examples of the many ways that we’ve been able to partner with clients. I think that this will continue to be an ongoing effort on our end to work in partnership with our clients to really improve access to care in the kidney care space.

Emily: Thank you so much for highlighting some of the work that Avalere is doing here. Thank you so much again to Brigit and to Grecia for being our panelists today and speaking about such an important part of our healthcare system reform and for helping to provide a snapshot of what is to come. We really appreciate all of our listeners for tuning into this miniseries.

For more information about our work, please visit avalere.com. Thanks again.

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