In 2001, the Institute of Medicine’s “Crossing the Quality Chasm” report identified six critical areas for improvement in the American healthcare system, urging fundamental changes to address gaps in patient safety, patient-centeredness and equity, among others.  

Since the report was published, the healthcare system has gained momentum in exploring and evolving value-based care programs to help improve clinical outcomes and enhance patient experience.

The Comprehensive Kidney Care Contracting (CKCC) demonstration project, the government’s largest value-based kidney care initiative, highlights how collaborative, interdisciplinary teams can positively influence patient outcomes.

Dr. Michael O’Shea, vice president of clinical affairs at DaVita, sat down with Dr. Gregory Spin to discuss how the “Crossing the Quality Chasm” report and value-based care models, including CKCC, can change kidney care. Dr. Spin serves as the clinical leader for the northern California CKCC group. He is also one of the founding partners of Summit Nephrology in the Sierra foothills. Their conversation explores the lasting principles outlined in the report, how value-based care models like the CKCC are helping to shape the future of kidney care, and the importance of sustained collaboration to enable ongoing transformation.

Dr. O’Shea: You and I have talked before about “Crossing the Quality Chasm” and how it’s given us a lot to think about. How do you think the report continues to resonate today as we think about value-based care?

Dr. Spin: Whether you’re in the medical profession or not, the concepts and issues identified in the report are front of mind for everyone in the United States. The problems outlined in the report are as or more relevant today than they were 20 years ago.

As physicians, we see these fractures in our medical system every day. They include but aren’t limited to, insufficient and variable penetration of providers and the resultant lack of availability, the need for patients to travel great distances, poor rural internet access and lack of telemedicine capacity, as well as lack of coordination between healthcare systems, labs and imaging and payors resulting in roadblocks to financial coverage.

We interface with the medical world less frequently as patients and family members of patients, but when we do, these deficiencies become even more obvious and can be even more frustrating and, in some cases, pretty scary.   

Value-based care allows us to reconsider the way we have traditionally worked — an extraction economy model focused on short-term gains — and apply solutions that require coordination and collaboration.

With value-based care models, we’re able to identify these gaps, the chasm presented in the report and build practice frameworks that will not only address these issues and improve outcomes for our patients, but also serve to stabilize our health care delivery system financially.

Dr. O’Shea: I couldn’t agree more. Would you go so far as to say that value-based care is going to be the answer that helps us cross this chasm?

Dr. Spin: Value-based care fundamentally changes our siloed health care system. It allows us to move away from that extraction model toward a more circular economy model.

We have known for a long time that kidney care is unsustainably expensive. It presents us with an express need for circularity and accountability. The 2019 Advancing American Kidney Health initiative (AAKH) recognizes that financial and clinical issues exist and sets parameters to help address them. A cardinal feature of the AAKH initiative is the engagement of value-based care at a larger scale.

In a value-based model, there is an understanding that we’re all interconnected, that we’re not in a zero-sum game. It allows us to appreciate that our clinical and financial goals can be aligned.

Fundamentally, when our patients do better, the cost of their care is reduced; when the cost of care is reduced, there are more resources available. Both patients and the providers do even better — and the cycle can continue. This is a circular economy model.

Dr. O’Shea: What changes do you see as necessary within the physician community to help deliver on this enhanced patient care?

Dr. Spin: Physician buy-in to these programs is fundamental. We need to help our partners, and our medical community see how we are interconnected as providers. By setting aside the competitiveness of the zero-sum game, we appreciate that we have opportunities to collaborate with each other, governmental organizations/payors, and with dialysis providers to create long-term success in this sustainable, healthcare model.

We are participating in this process and recognizing that it requires upfront investment, both financial and intellectual. You can’t make a circular process work unless you make these commitments. It is necessary to have buy-in from all parties to make this happen, to make it sustainable.

Some of the earlier value-based care models had limited adoption and buy-in. Many nephrologists didn’t participate in these elective programs. The CKCC model was the first value-based program that my practice participated in, outside of some small clinical incentive programs.   

This program had a component of compulsion, and it got everyone’s attention. You were either going to have the chance to participate electively in a CKCC, partnering with organizations like DaVita and other practices that you had a choice to align with, or there was a good chance you could simply be enrolled without much autonomy and control of partnerships.

Dr. O’Shea: You highlight the need for energy in this transition, which I think can be an important factor as we consider the changes we’re making. Building on that, what challenges do you see playing out as we seek to create and observe these transformational shifts?

Dr. Spin: Right now, there is a risk of getting out, or “checking out” too early. There has been some disappointment in the lack of financial remuneration in the first couple years of the CKCC. There has also been a need for development of our clinical programs before the full clinical benefits can be realized. We are seeing, as expected, improving financial and clinical outcomes across the CKCC landscape. I find it helpful to consider that the macro-data outcomes that we are seeing represent many individual outcomes, and that each optimal dialysis start that wouldn’t have otherwise occurred, results in a significantly improved patient experience with it’s associated beneficial effect on morbidity, mortality, and cost to the system. We have all seen these “wins” for our patients, a direct effect of the collaboration with our CKCC partners.

Dr. O’Shea: Your belief in transformation and reform in healthcare is clear, and what I appreciate is the value that you place on the importance of gratitude in driving these changes. How do you think about gratitude in working with external entities outside of the practices, as we try to streamline healthcare?

Dr. Spin: Gratitude, of course, is best as a daily practice. It’s more than a feeling: It’s a fundamental mindset that informs everything we do, including our patient care.

Gratitude grounds us; it connects us to each other and reminds us why we do what we do.

Value-based care provides an opportunity to stabilize and start to rebuild our fractured medical system. But that opportunity also requires a significant investment in collaboration. Gratitude enhances all forms of collaboration, whether it’s between you and your patients, with providers in your practice, other practices or large health systems. It helps to build relationships.

We started our practice 20 years ago, and the cracks in the fee-for-service system are obvious to us. Large multi-specialty health groups — let alone smaller, single-specialty practices like ours — can find themselves needing to anchor to other provider groups and health systems to provide necessary care to our patients. We simply don’t have all the resources to provide optimal care otherwise. Through participation in value-based care, we have been able to improve the care that we provide to our patients.

DaVita has been a trusted partner of ours for many years, and this partnership helped make the transition to value-based care comfortable. As we came together, the process was informative and educational.

It comes back to the idea of creating trust and collaboration across practices and gratitude for the others we work alongside. By adding a gratitude practice to our meetings and touchpoints, we can better understand how we are interconnected. We can remind ourselves why we are involved in patient care and better appreciate collaboration with other groups.

Dr. O’Shea: This gratitude and collaboration really emphasize that sense of teamwork you talked about earlier. In addition to incorporating gratitude practices to how you convene, do you have any advice for nephrologists, regardless of where they are in their career, as they consider their participation in value-based care?

Dr. Spin: Value-based care is a balancing act, and we all need to be part of this process. The promise of change outweighs the temptation to stay the same. Not be excessively “Rah! Rah!” but what is the other option? To continue with our current extraction model that is resulting in unsatisfactory patient outcomes and is financially untenable?

It is challenging to alter your current workflows. That being said, recognizing care gaps and the best way to correct them can only come from experiencing them as physicians, patients, and family members. Experienced nephrologists are not only going to participate in these programs. They are going to lead them.

Younger doctors are in a great position to contribute to and expand the level of the partnership that value-based care requires. Today’s medical training has a focus on collaboration, so they tend to recognize the value of these approaches.

Value-based care requires an “all hands-on deck” approach. Our patients, our providers, our practices and our greater national community can’t “afford” to miss out on this opportunity.

Value-based care, when meeting its potential, is transformational.

It’s a very cool time to be a nephrologist.