With over 160 specialties and sub-specialties in the US, there has been no shortage of venture-funded, value-based specialty care organizations over the last ten years. Examining these specialties, there are several factors that make for an attractive opportunity:

• High cost: If the specialty is costing insurers and patients a lot of money, there is more opportunity for savings.
• Variable cost: If there’s a significant difference in the amount of money spent on different care pathways, there is more opportunity to reduce costs.
• Variable quality: If there’s a significant difference in the quality of care and patient experience across different care pathways, there is more opportunity to improve quality.
• High patient level costs: If costs are concentrated with fewer patients, it is easier to leverage targeted interventions and have an outsized impact on cost in a smaller population.
• Independent specialty: If the specialty is owned and operated independently, rather than by an incumbent risk-bearing entity or health system, the independent specialists are more likely to need assistance in transitioning to risk.
• CMMI model: The factors above contribute to CMMI’s creation of models, and a model has always spurred innovation.

If a statistic in this section does not have a source, it comes from this PDF 👇

William Blair Report on Specialty Value-Based Care.pdf

Kidney care

Kidney care is well-suited for risk-based models because it is a high cost and discrete condition. In these risk-based models, nephrologists deserve accountability for total cost of care due to the discrete nature of the condition, which policy makers & CMS have recognized.

First, let’s take a look at cost. Medicare is spending over $50B per year on End-Stage Renal Disease (ESRD), which is roughly 1% of the overall federal budget. The average dialysis ESRD patient costs roughly $100K per year, and there are roughly 800K ESRD patients (68% of whom are on dialysis). This high cost creates more opportunity for savings.

Next, looking at the condition, Chronic Kidney Disease (CKD) (the precursor to ESRD) affects roughly 15% of the population and is much more prevalent in Medicare (38%) than other populations. Despite its prevalence, it is estimated that [90% of patients](https://pmc.ncbi.nlm.nih.gov/articles/PMC8740927/#:~:text=An estimated 37 million Americans,people at risk for CKD.) with CKD don’t know about their condition. Kidney disease is a discrete disease state where a specialized care model improves outcomes, reduces costs, and increases patient satisfaction. Deploying this specialized care model, nephrologists often are the quarterbacks of the condition as a relatively independent specialty (not employed by health systems). This dynamic is dissimilar to a condition like diabetes, where PCPs manage the condition because of its prevalence, familiarity, and straightforward management protocols. In this care journey, nephrologists and care managers can positively impact care in a number of areas:

• Slowing disease progression
• Increasing optimal starts (beginning dialysis with a permanent vascular access already in place, rather than a catheter)
• Reducing hospital admissions / readmissions
• Movement from in-center to home dialysis