7. Why Kidney Failure Pays
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Description
America’s relationship with Dialysis is out of control. Roughly 1% of the entire federal budget is spent treating people with kidney failure. That’s billions of dollars devoted to treating one preventable illness. How did we end up with so many people on dialysis? And who’s getting rich from it? This week, we connect the dots from Richard Nixon to Dr. Evil and talk with disruptors who have some new ideas for how to fix the system. Bobby Sepucha, Will Stokes and nephrologist Dr. Natasha Dave join us to talk about how these kidney care disruptors are prioritizing patients and their overall health.
Resources from the episode:
- Learn more about Strive Health’s Kidney Heros: https://www.strivehealth.com
- Read up on Cricket Health’s kidney care model: https://www.crickethealth.com
- Listen to Dr. Dave’s podcast on life as a nephrologist: https://www.kidney.org/podcast
Keep up with David on twitter @CHIDavidSmith.
Share your feedback! Email us at costofcare@lemonadamedia.com or leave us a voicemail at 833-453-6662.
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Transcript
SPEAKERS
Will Stokes, Dr. Natasha Dave, David Smith, Bobby Sepucha
David Smith 00:00
Hey listeners, the COST OF CARE is a 10-part series. We think it’ll make more sense if you start from Episode 1. So go back, start there, and we’ll be here when you’re ready.
Bobby Sepucha
The standard of care in this country is for 60% to the 65% of people who go on dialysis, they do it by what we call crashing into dialysis.
Will Stokes
Over half of patients really about 60%. Their kidney care journey starts with a kidney failure event. They may have diabetes, hypertension, other common comorbidities, but their kidney disease is asymptomatic, they probably don’t know it exists.
David Smith
That’s Will Stokes and Bobby Sepucha. Two co-founder CEOs with startups looking to disrupt the kidney care industry, which is critical, because if you’re looking for a case study that embodies everything that’s wrong with the American healthcare system, you’re not going to do much better than the way we approach kidney care in this country.
Bobby Sepucha
There are 36 million Americans with kidney disease today. 98% of whom have no idea they have the disease. Even those who are late-stage kidney disease, stage four, stage five, half of those folks don’t know they have it.
Will Stokes
And they become aware that they have the disease when their kidneys have already failed. They have a traumatic what’s called a Dialysis Crash.
Bobby Sepucha
So they will show up in an emergency room somewhere in their neighborhood and say, I don’t feel good, I have blurred vision, I have chest pains, I don’t know what’s wrong with me, the doctor runs a blood test and says your kidneys have failed, you’re on dialysis today. And for the rest of your life, they haven’t prepared for it, they don’t even know they’ve had it. They certainly haven’t managed their meds or the diet or anything else.
Will Stokes
90% of patients then are on hemodialysis where they have to go to a center three times a week to receive dialysis care. So today, the system is very reactive. A lot of the infrastructure and clinical care is focused on the end of the journey post kidney failure. Very few patients are receiving kind of proactive preventative holistic care ahead of that kidney failure event.
Bobby Sepucha 02:08
So the big tragedy from my perspective, I think from a lot of observers perspective is that all of the time, attention and focus in this country has been on the half a million Americans on dialysis, and virtually none in an organized fashion on the 36 million with kidney disease prior to kidney failure.
David Smith
Our country’s relationship with dialysis is out of control. America spends more on dialysis than any other nation on Earth. Roughly 1% of the entire federal budget is spent treating people with in stage renal disease, and that equates to hundreds of billions of dollars devoted to treating one preventable illness. And for once, it’s actually pretty easy to trace how we got to where we are today, is this classic case of what happens when well-intentioned policies get twisted by the misaligned profit incentives of the industry, all within this environment where social factors make it incredibly difficult to live well. This is the COST OF CARE. I’m your host, David Smith.
David Smith
So if you’re not already familiar, dialysis is a process where a machine basically acts as your kidneys by filtering your blood. It comes into play when a patient reaches end stage renal disease, also known as kidney failure, which as you heard up top is unfortunately the stage when most patients enter the system. If we have the science and the ability to catch it earlier, why is it that we have this imbalance or this asymmetry for these patients?
Will Stokes
Yes, there’s the classic problem of fee for service medicine. Nephrologists really don’t get reimbursed that much, they have very little incentive, often disincentive financially, to see patients when there’s chance to slow disease progression, maintain kidney function. And in this case, the services for kidney care that are reimbursed and reimburse well at high rates is really just dialysis.
David Smith 04:25
Every time I asked the question, and I asked it a lot, why don’t we invest in prevention? I pretty much already know the answer is going to be some version of because sickness pays. But in the case of dialysis, like it really, really pays. And it turns out, there’s a historical backstory for this.
Bobby Sepucha
Well, I think in many respects, it goes back to what happened in 1972 when the Medicare benefits for dialysis was first enacted.
David Smith
That’s Bobby Sepucha again, co0founder of Cricket Health.
Bobby Sepucha
Back in 1972. What happened was dial This was still a relatively new treatment. Prior to that, if you were diagnosed with kidney failure, it was effectively a death sentence. So in the 60s, as dialysis started to proliferate, it was too expensive for people to access. And so local communities, whether it was in Boston or Seattle, would often form committees of lay people of clergy, of physicians to come together. And they started to meet at night, almost in secret to evaluate people who had been diagnosed with kidney failure to decide quite literally, who would live and who would die, who would get dialysis and who would not.
David Smith
Remember when people tried to peddle the idea of death panels back in 2012? Well, those were fake. But back in the 1960s, they were actually kind of a thing. Dialysis was this new, groundbreaking lifesaving treatment, but it was prohibitively expensive. So these panels of physicians, nurses and community leaders would convene to decide who deserve access based on how much the patient can potentially contribute to society. Those deemed highly valuable by the panel received dialysis and those that didn’t, died.
Bobby Sepucha 06:12
Not surprisingly, this was not a satisfactory state of affairs for most people. And so lots of lobbying happened to try and get Congress to step in. And they did, they did something remarkable. They said, if you’re 5 or 65, doesn’t matter how old you are, if you’re on chronic dialysis, you’re eligible for Medicare. At the time, it was monumentally saved without question millions of Americans lives.
David Smith
In 1972, President Nixon, that’s right socially and fiscally conservative Nixon signed a law codifying this lifelong subsidy for dialysis patients. And this presented an immediate market opportunity.
Bobby Sepucha
As soon as Medicare conferred automatic eligibility on end stage renal disease, what they did is they put a pot of gold in the dialysis space. And so that’s where the money was, that’s where the reimbursement was. And that’s where you start to have companies like DaVita, like Fresenius start to emerge and to grow by creating dialysis clinics.
David Smith
Today, there’s about 7500 dialysis clinics throughout the US, two thirds of which are now owned by two industry giants, DaVita and Fresenius. What started as a way to make treatments streamlined and accessible, quickly became a booming business.
Bobby Sepucha
I don’t think anyone at the time however expected either of two things to happen, one the sheer number of people to have kidney disease to explode like it as and to the cost of that care on an individual and aggregate basis to explode like it has.
David Smith
When that law back in 1972 was passed, there were only 10,000 patients receiving dialysis in America. Today, there’s nearly half a million, and dialysis sucks. Most patients have to go to the clinic three times a week for three to four hours per session where they’re strapped into a chair. And it’s a huge strain on the body.
Bobby Sepucha 08:09
Effectively, once you go on to dialysis, it’s a massive stress test on your cardiovascular system. So mortality spikes dramatically. If you annualize the mortality rate for the first 90 days of dialysis works out to about 40%.
David Smith
Remember, patients usually start treatment once they’ve already reached kidney failure. This is a really sick population that’s often been neglected up to this point by the system. Plus as for-profit chains, like DiVita and Fresenius, bought up independent clinics, their goal was to run a lean business. That means more patients, fewer clinicians and less time to disinfect stations in between treatment. There have been lawsuits and settlements to try to correct those challenges. But the number of patients in need of the care just keeps rising.
Bobby Sepucha
All of this leads to really horrible health outcomes for patients and exploding costs for the system at large. If we weren’t all take a few minutes and try to imagine the worst possible health care delivery system for these patients, there’s a decent chance we’d come up with the current system.
David Smith
So the current system is clearly a disaster. But it’s worth digging a little deeper into the why. Because on the outside, it kind of seems like the way we pay for kidney care is what many people are advocating for today, Medicare for All. In this case, it’s just Medicare for all kidneys.
Bobby Sepucha
The opponents will say well look at kidney care. You know, that’s the that is the closest we’ve got to single payer system and it’s we’re gouging payers. And therein lies the rub. Kidney care is not a single payer system. It’s a hybrid. So today about, because of the Medicare benefit. About 90% of Americans were on dialysis or paid for by the federal government. Easy question, Bobby is well waiting a second. You just told me there was a Medicare benefit. Why isn’t 100% Well, in order to try and create some sort of cost sharing, because the number of people on dialysis have exploded, and that was just a really huge cost for the federal government to try and bear, they reached out to the private industry to private insurance. And by reached out, they passed a law that said, hey, if you have group health insurance, you get to keep that for a period of time, even after you’re on dialysis. After that period of time expires, you’ll go to Medicare will foot the bill, but for a while, Stan, your primary insurance. And today that’s about it. The deadline is 30 months.
David Smith 10:32
A booming business cropped up in the wake of the Medicare reform. But as the number of dialysis patients skyrocketed, the reimbursement amount has not. And you know, what happens when the medical industrial complex feels like they’re not making ends meet? They look to private insurance to make up the difference. This loophole provides two years for clinics to make as much money as they can from those private insurance companies.
Bobby Sepucha
Now, the challenge has been is that the differential between Medicare and the commercial rates has become fairly dramatic. And in fact, there are an awful lot of providers out there dialysis providers who will gain the system and they’ll figure out what geography they can they open a clinic where they can have that split be as high as possible. And so insurers blues plans, and the national insurers get very frustrated because they say Medicare’s paying $250 for treatment, and yet for our dialysis patients. We’re paying many, many multiples of that. And that’s why I think in this space, we’ve moved well past payer frustration, and we’re into payer rage.
Bobby Sepucha
Now again, the dialysis providers will come back and say this is cross subsidization. This happens in every segment of healthcare. And that’s a fact. It’s particularly pronounced in dialysis, because of the fact that so many are paid for by the government. And the government’s not going to cover our costs. We have to make it up somehow. That’s a true statement. But I think from the insurance company’s perspective, I think they’re looking at this and saying, well, you’re I think you’re gouging us. And so that’s where the frustration has been for a long time.
David Smith 12:02
That frustration is so well earned. Over the last decade, there has been a lot of questionable practices. Industry giants DaVita and Fresenius have found themselves in hot water after whistleblowers came forward and uncovered shady business practices between the for-profit clinics in the leading charity the American Kidney Fund. Basically, the American kidney fund helps patients get on to private insurance to pay for care. There’s a lot of reasons proponents cite for why private insurance is better than Medicare, but basically the pitches, you’ll get better quality of care and will cover your premiums, which sounds great, right?
David Smith
Well, it turns out that 80% of the American Kidney Funds revenues come from donations by DaVita and Fresenius. The big chains pay the kidney Fund, the kidney fund pays the premiums. And then the big chains can turn around and charge private insurance up to four times what they’re charging Medicare. And again, I know it’s hard to sympathize when private insurance gets stuck with the bill. But this is a big reason why premiums are soaring. Now, this all sounds pretty evil. So it’s kind of an awkward time to tell you that Bobby used to work for Fresenius. In fact, it was his job to lobby Congress to raise those Medicare rates to try to even the playing field. And believe me, I asked him again and again to dish the dirt on the Dr. Evil behind the scenes at Fresenius.
Bobby Sepucha
Well, certainly there’s been no Dr. Evil moment when I was there.
David Smith
Okay, that’s incredible. I was really hoping to paint a picture for me.
Bobby Sepucha
It makes for bad podcasting, but at least it warms the heart just a little bit. It is really easy to take a step back and just try and find the singular actor or the singular villain. I don’t think there’s one villain in the story. You know, I spent almost nine years at Fresenius, as they as a large dialysis provider are often picked as the easy villain. I will tell you that all the people who work there are phenomenal.
Bobby Sepucha 14:06
The caregivers, the execs, everybody is dedicated to trying to help patients. But the incentives that have evolved over time are perverse. I think the bigger challenge is that there’s all the incentive of the world in the world for the exact same for the folks who are, you know, throughout the company, of just preserving the status quo, partly because it’s easy, this is the way we’ve always done it, but part of the because that’s how they get paid.
David Smith
This is the really unsatisfying truth at the core of our system. As rotten as it all seems. From the outside, it’s generally filled with mostly decent people just looking to do their job and get paid. Until we overhaul the payment system. Things aren’t really gonna change. And this is why people like Bobby have left the big chains to build out new value-based models like the ones Vivian talked about a couple of episodes ago. After the break, we’ll talk about why that’s so important from the patient perspective.
David Smith
We’re back. Stories about the kidney care industry often focus on the bad guys. And trust me, I get it. There’s a ton to say about the bad guys. But who are the people actually impacted by chronic kidney disease? To learn more, I sat down with Dr. Natasha Dave, she’s a nephrologist, a.k.a a kidney doctor at Strive Health.
Dr. Natasha Dave
You know, if I were to think about who walks through the door, for my clinic, the majority of my patients are older, as kidney disease is often an illness that you see around the seventh decade of life, especially if you have medical conditions such as diabetes and high blood pressure. And unfortunately, many patients are not either told about kidney disease or don’t understand kidney disease well, when I see them in clinic.
Dr. Natasha Dave 16:07
You know, I’ve had a couple of patients that said, I don’t know why I’m here, my primary care doctor referred me to a kidney doctor. So my first visit with patients really revolves around educating them about their kidney disease, where are they, as far as you know, kidney disease progression? Where are they now? How can we stop? You know, their kidney disease from progressing towards dialysis? And what are some of the things that we can do to help.
David Smith
Even though most patients find out they have kidney disease, once they’ve hit kidney failure, it’s entirely possible to catch people much earlier when there’s still time to turn things around. This is super important because the population most at risk is often totally left behind by the medical system.
Dr. Natasha Dave
You know, we see a huge amount of disparities in the African-American and Latinx communities. A lot of these patients unfortunately, lack pre dialysis care. One contributing factor is healthcare access. A lot of them may not have insurance or don’t have good access to going into a clinic. They’re working, you know, multiple jobs. But it can’t really be completely explained by lack of access or insurance. There’s a whole complex interplay when it comes to social determinants of health that likely contribute to this as well. So it could be something as simple as like housing instability or access to healthy food or stress or transportation. There’s this web of multiple factors that can contribute and even exacerbate these disparities.
Bobby Sepucha
It is inextricably linked to food deserts. It’s inextricably linked to the lack of high-quality fresh foods, there’s just no question about it. It’s part and parcel of the obesity epidemic here in the US. Hypertension and diabetes are the two biggest drivers of kidney disease. So, in order to really tackle kidney disease, you have to tackle obesity. In order to tackle obesity, you have to go upstream into all the psychosocial social determinants of health issues that you can think of. And no surprise, as we Americans continue to eat more and more Big Macs, we’re contributing to obesity, which contributes to kidney failure.
David Smith 18:24
And that, that is exactly where I want to go. By the way. I’m feeling really sheepish right now, because I had a Big Mac for lunch. I’ve guilted myself already. But now. Now I really feel the weight of that, no pun intended. Okay, so I’m going to level with you guys. I did eat a Big Mac that day. And if I’m being honest, depending on what’s going on in my life, on any given day, I often turn to take out, I don’t eat Big Macs, because I live in a food desert. I eat them because they’re fast and delicious. And that’s what I turn to when I’m having a crazy day at work and I just need something comforting and convenient.
David Smith
And trust me, it would be so much easier for me to have the producers edit out my little confession. And frame food choices is the thing that some people need to learn. But Americans at all socio-economic classes have a complicated relationship with processed food. It’s one thing to know that a stock of celery is better than a juicy Big Mac. But it’s an entirely different thing to make that choice and adopt a totally new lifestyle, especially when time and access are constantly working against you. And we’re all dealing with these high levels of stress and anxiety. I promise you; I understand the no one really wants to talk about changing their diet. I don’t want to talk about changing my diet. But in this case, what we eat has real consequences.
Dr. Natasha Dave
Adhering to a healthy lifestyle really does help not only with kidney disease but with quality of life. I always tell my patients that in some countries, they consider food, medicine, it’s really important that we understand what we’re putting into our bodies to avoid processed foods as those are associated with creating inflammation in the body, really making sure that you stay hydrated. These are very, very important and getting plenty of exercise and, you know, sunlight. These are, I can’t stress the importance of this. But unfortunately, this may seem intuitive to you and I.
Dr. Natasha Dave 20:28
But someone that’s suffering from multiple medical conditions, you know, having to work and take medications and track things, it can be very overwhelming for them, and they don’t know where to start. And that’s why it’s really important that physicians along with entities, such as Strive really sort of push having this dialogue with patients and breaking it down into bite sized pieces where they can sort of understand their illness and how they can sort of combat some of the issues that they’re facing.
David Smith
So listen, encouraging positive behavior change for patients is definitely important. But there’s a lot of change necessary within the industry itself.
Dr. Natasha Dave
There are so many gaps in kidney care, unfortunately, we currently practice in a system where we have 15 to 30 minutes to see a patient for appointment. And that’s just not long enough, it’s not enough time to really understand what are the barriers patients are facing and to provide in depth education. It’s almost like you’re practicing in a revolving door of patients. Given this, I think the first barrier I have to mention is education, we should provide a lot of education to patients, so they understand that they can actually slow their progression of kidney disease. And we have to do this early in the process before it’s too late, where there’s too much scarring that’s occurred in the kidney, and we can’t sort of act upon it.
Dr. Natasha Dave
Another barrier along this line is misinformation online. So we need to directly combat this information in clinic before patients are harmed either physically or financially. There are some other barriers, one that I’ve really noticed is late referral from to a nephrologist or to a nephrology clinic. I’ve seen this many times where patients are sort of referred when their kidney disease is very advanced. And unfortunately, so shocked to them. We need to work with our primary care colleagues to educate them on when to refer patients. And actually in the last couple of years, there’s been very good evidence to support that early referrals associated with great outcomes.
David Smith 22:41
In a perfect world, primary care physicians would be on the frontlines of prevention. But that’s hard when you think about the two most common scenarios for how people interact with primary care. The first is the patient just isn’t seeing a primary care doc. And this is pretty common. Either you’re under insured, you don’t have easy access, or you just don’t want to go to the doctor’s office. But number two is you are going to see your primary care doc.
David Smith
But because of that fee for service monster, you really only get like 15 minutes of one-on-one time. So the doctors just focusing on the big stuff. They’ll address hypertension and diabetes, and so you lose weight. But they may not take the time to address the next possible steps down the line that could arise from those issues. They won’t send you to a nephrologist early on or tell you clearly hey, these conditions could lead to kidney failure. And this is what life with kidney failure looks like.
Dr. Natasha Dave
Along the same line. If we’re talking about late referrals, we need to bring up pre emptive kidney transplantation.
David Smith
Honestly, we could do a whole episode on kidney transplants. But the long story short, it’s one of the most effective forms of treatment, but there’s still a ton of barriers. You have the industry giants doing everything in their power to keep people in dialysis chairs. The qualifications to get a kidney are prohibitive. And the cost to donate your kidney are also really high. And no one in the system has the right incentives or enough time to make thoughtful decisions.
Bobby Sepucha 24:13
I was visiting with one of the largest practices in the country about three weeks ago. I was talking with their head doc, this is a very successful practice both clinically and financially to be crass, but they’re all forward thinking. incredibly well-regarded practice. And I asked the doc I said for a patient of yours who is about to, was approaching kidney failure. He or she is going to need renal placement therapy and they’re deciding between transplant referral home dialysis, in-center dialysis, the modality selection decision, how long do you spend with that patient? And he said well, about 20 minutes. And I said wow, that’s remarkable. I mean this patient is you know; this is probably the single biggest or one of the two or three biggest decisions they’ll have to make literally for the rest of their lives.
Bobby Sepucha
And he said without question. He said I’m not proud of it, it’s all the time that I have, we don’t have the necessary follow up at the practice, I’ll send them to a DiVita or Fresenius clinic, they do treatment option education. But even that, that’s an hour, 45 minutes to an hour in a conference room with a bunch of strangers. This poor patient is scared, doesn’t know what’s happening, trying to scribble down notes, a bunch of terms are being thrown at him or her that it’s just how do you wade through it? So it’s no wonder that when they would, when the question was posed to them, they’d look at the doc and say, well, what do you think?
David Smith
And the answer is usually go to the dialysis center down the street, it’s easier and most doctors are more familiar with in-center dialysis than the at home process. And this has a big impact on the numbers. In America, our rate of patients receiving dialysis at home is sitting around 12%.
Bobby Sepucha
Other countries, Singapore, New Zealand, Australia, parts of Italy can be at 50%,60%, even 70%. And home dialysis patients have a higher quality of life, they typically are hospitalized a lot less frequently. They involve less cost, it’s better for the system, and certainly better for the patient. So the question for a long time has been why on earth don’t we have a higher home penetration rate, meaning the percentage of dialysis patients who are treated at home. Why is it so low? And the answer is it’s complicated, it’s easy to point it to DiVita and Fresenius and say, well, it’s their fault, because they just have an incentive to fill their chairs in the clinic. And that to be sure as part of it, there have been some terrible stories document in the press about some of our care managers saying don’t do home dialysis, it’s too hard, you should just do it in-center, we’re a family here.
Bobby Sepucha 26:33
But it’s also because the disease impacts people at a lower socio-economic spectrum here who may not have the home environment that would support home dialysis, the place to store all the machine and the supplies the caregiver who can help them stick a needle in their arm. It’s also the fact that lots of doctors here in America are just not trained on home therapies, especially the newer ones, which is counterintuitive. So it’s a multifactorial problem that deserves and warrants and demands a multifactorial response. And yet, we’re only starting to do that as a healthcare system. It’s going upstream and prevention and health and wellness and awareness. It’s also this basic blocking and tackling about training more docs on home, about figuring out easier ways of providing dialysis at home, and so on and so forth.
David Smith
These options aren’t just preferable for patients to have a better quality of life, they’re also more affordable. Here’s Will Stokes, co-founder of Strive Health again.
Will Stokes
chronic kidney disease patient may cost the system $20,000 a year. Dialysis patient costs the system $100,000 a year, the crash into dialysis alone cost the system between $40,000 and $70,000. Just for that event. If we can avoid those things if we can avoid that dialysis experience if we can avoid that dialysis crash. If we can avoid unnecessary hospitalizations that are about $10,000 to $15,000 per hospital admission, if we can avoid those things that’s we can bring down total cost of care. And that’s where our incentives […].
David Smith 28:09
After the break, we’ll hear how value-based companies like the ones led by Bobby and Will, are disrupting the system by working upstream.
David Smith
We’re back. In the last episode, we talked about bio psychosocial health factors, this idea that everything is interconnected from our biology, to our psychology to our social setting. Think about it like a car. The vehicle itself is like your body. Taking care of the biology of your car means checking on the mechanics has the oil been changed? Does it have enough gas. If not, it’s probably not going to run very well or get you very far. But let’s say all systems are ago, well then you’d look at the driver. They’re like your brain, your mental health. If they’re distracted and […], they’re sleep deprived, they’re less likely to drive the car safely.
David Smith
But then, there’s the world around you. You can have a current perfect condition with a driver who’s at the top of their game, but then a blizzard hits and you can find yourself driving on a windy road with zero visibility. Focusing on any one element alone isn’t going to get you home safely. If you’re working downstream, you’re not worrying about your tires or checking the weather until you’re basically about to drive off the road. But thinking upstream means making sure all of the conditions are optimal before you get behind the wheel. When it comes to health care, it’s much easier to take an upstream approach when you have a dedicated team. That’s what’s happening in Strive Health.
Will Stokes
So we call our caregivers kidney heroes, and every patient they’re responsible for as in panel to a team of kidney heroes, a nurse practitioner, and then some care extender resources like dieticians, case managers and otherwise. And with that team, that team has a finite number of patients that they’re responsible for and have a relationship with that know their patients very intimately. And then they’re available 24/7, and then they’re able to solve, really any need a patient can throw at them. They’re not just there to talk about kidneys, or talk about problems with cleanliness in the home, they’ll talk about the fact that your patients not able to find a ride to their doctor’s appointment the next week.
Will Stokes
They’re there for anything, and then they’re taking the time to actually follow through on that. They have the time and capacity to show up in the home and unpack groceries or bring groceries, they can get rides arranged to that doctor’s appointment, they really can solve a wide range of issues because they’re focused on that holistic patient experience. And they’re always available there for that patient.
David Smith
Nephrologists, like Dr. Natasha Dave, are key members of these kidney hero teams.
Dr. Natasha Dave 31:14
We combat these roadblocks by really establishing strong relationships with all members of the patient’s health care team. So primary care physicians, nephrologists and vascular surgeons, we also really believe in relentless patient follow up, we track these patients progress very closely. And many of these patients can kind of be overwhelmed with the information that they’re provided during a physician visit. A lot of times they’re like, I walk into my doctor’s office, I wait for an hour, I see them for 15 minutes, it is a blur. So we sit down and we really talked to them about what do kidneys do? Why do we need them? Why are they important? How can we save our kidneys.
Dr. Natasha Dave
And we also kind of create these care plans. Each patient has kidney disease as a result of something, for example, it could be diabetes that are contributing to kidney disease or high blood pressure. So what we do is we create these care plans and we create these goals with the patient. We’re sort of like a health coach. We break down goals into bite sized pieces, and then we track the progress for patients. And I believe this is why we’ve been so successful.
Dr. Natasha Dave 32:28
Furthermore, I think we kind of talked about social determinants of health. But we dive deeper under the surface with trying to understand our patients, we actually look at social determinants of health and screen for it. And we try to combat these problems as they arise. What we always say is we don’t wait for the patient to tell us that they’re having problems, we actively engage them to find out what problems they have and we try to combat them.
David Smith
Strive Health is not alone. Bobby Sepucha’s startup, Cricket Health, is adopting its own model of upstream care.
Bobby Sepucha
There are three components that we really focus on. One is figuring out who are the right patients to provide care for. We talked about how is an under diagnosed, so we have to unearth those patients.
David Smith
Bobby’s team is working to identify patients earlier around stage three, when the patient is 18 to 24 months away from kidney failure.
Bobby Sepucha
We’ve developed a tool of data algorithms and analytics that can identify if a patient has kidney failure just by looking at their claims. So they haven’t been diagnosed there is no claim for kidney disease. But by looking at kidney adjacent claims, hypertension, diabetes and other things, we can predict with about 90% accuracy, not just if they have the disease, but what stage they’re at. So now we know who is the right patient to provide care to, now what’s the right care? For us. It’s about changing behavior and can’t change behavior until there’s real truly engagement. And there’s not to be true engagement unless there’s relationships of trust.
David Smith 34:00
They’re also trying to avoid that scenario where a patient has 20 minutes to learn about and decide what kind of treatment they’re going to receive for the rest of their life. Cricket Health has a whole digital library of videos and FAQ’s.
Bobby Sepucha
And critically, our clinicians can see what our patients are watching and see what they’re reading. So while that sounds like Big Brother, what it enables us to do is trigger automatic workflows that Mrs. Jones has just watched two videos about home dialysis and read three FAQ’s about peritoneal dialysis versus home hemo. Our nurse can call the next morning and say Mrs. Jones, I see you’re thinking about home dialysis, would it be helpful to talk to a patient peer mentor who’s been on home dialysis for last five years, we’ve really started to unlock engagement, which has led to, you know early indications that we’re reducing hospitalizations to the tune of about 65%.
Bobby Sepucha
So it’s been really terrific to see. Clearly this is an older population, not everyone’s facile with the internet so we can still engage with people over the phone, we can engage with people over video we can send materials home, we can-do in-home visits and doing home visits for high-risk patients. So it’s a multi modal approach, you have to create a real relationship of trust.
Dr. Natasha Dave
Trust is really the foundation of the doctor-patient relationship. We need to build trust with our patients by listening to them. It is so incredibly important to understand who your patient is, when it comes to understanding what the right dialysis modality would be or what the right treatment plan is for a patient and sort of what are the barriers that they’re facing and how can we combat them, we need to understand what motivates our patients what rituals they have, how their day is structure, and what they value when it comes to their health. This is so crucial when it comes to providing good kidney care.
David Smith
So here’s the bottom line. Trust is crucial when it comes to providing any kind of quality care. But kidney care has historically been especially blatant when it comes to prioritizing profits over patient health. So it’s going to take a lot of time, hard work and dedication to turn that perception around. Next week, we hear what that kind of work looks like on the ground for all medical disciplines. We’ll sit down with three women who have been talking to people all over the country to hear what’s missing, and what we can do to finally fix our broken system. They just
Speaker 4 36:29
They just want to be heard. They want to be listened to. They want to be valued, not treated like a second-class citizen, not thrown through the system is just another number because people feel that. But just another number is a life. It’s a brother, a sister, community member, and sometimes I feel like they have this sense of alienation.
CREDITS
The COST OF CARE is a Lemonada Original. The show is produced by Jackie Danziger and Kegan Zema. Our associate producer is Giulia Hjort. Music is by Hannis Brown. Executive producers are Stephanie Wittels Wachs, Jessica Cordova Kramer and David Smith. Help others find our show by leaving us a rating and writing a review. If you have a story to share, call us at 8334-LEMONADA or send us an email at costofcare@lemonadamedia.com. Follow us at @LemonadaMedia across all social platforms or find me on Twitter at @CHIDavidSmith. Lastly, we want to express our appreciation for the men and women who get up every day and work in this system with a passion for improving our health. We are grateful for the work you do. We’ll be back next week.
