“New Deal” for Kidney Care for US Veterans Outlined

Results of recent analyses have shown that veterans receiving care from the Department of Veterans Affairs (VA) healthcare system are experiencing improvements in kidney health outcomes. Susan T. Crowley, MD, and Katherine Murphy, MHSA, employees of the Veterans Health Administration, suggest that “scrutiny of the agency’s current care model may identify population health initiatives associated with improved outcomes that could potentially be adopted by other healthcare systems.” The authors offered their perspective on Delivering a “New Deal” of Kidney Health Opportunities to Improve Outcomes within the Veterans Health Administration online in the American Journal of Kidney Diseases [doi:10.1053/j.ajkd.2018.01.056].

Rates of risk factors for chronic kidney disease (CKD) in the veteran population exceed those in the general population; rates for diabetes mellitus, hypertension, and overweight/obesity in veterans are 24%, 46%, and 78%, respectively. Estimates of CKD among the VA population range from 4% to 36%, rates that are also higher than in the general population: the prevalence of stages 3 to 4 CKD in the VA population in 2011 was 11.1%, compared with 6.7% in the general population in the United States.

Sixteen percent of VA enrollees, more than one million, are diagnosed with non-dialysis-dependent CKD (NDD-CKD). Compared with veterans without CKD, those with CKD are older (78% are >65 years of age), and 68% are nondiscretionary enrollees, having either a military service-connected disability or meet the low income criterion for VA care.

Estimates of aggregate expenditures for veterans with NDD-CKD demonstrate that while costs increase by CKD stage, the majority of expenditures are associated with the large population with stage 3 CKD. During the past ten years, total annual costs of care for the NDD-CKD population have increased steadily, to $18 billion in fiscal year 2016.

Beginning in the 1990s, the VA moved from an acute hospital care provider model to a prevention-focused primary care model. In 2010, the VA’s primary care model was expanded to a comprehensive patient-aligned care team (PACT); kidney care is delivered through the PACT in a model focused on health promotion of longitudinal care. Collaborative primary-specialty care partnerships are supported by evidence-based policy, universal electronic medical records, performance measurement, teletechology-enabled access, research, innovation, and veteran education.

Indications for nephrology consultation include estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2; evidence for a rapid decline in eGFR (>5 mL/min/1.73 m2); when complications of CKD (i.e., anemia or abnormalities in calcium or phosphorus) arise; when nephrotic-range proteinuria exists; when the underlying cause of CKD or proteinuria is unclear; or when the patient’s severity of disease exceeds the primary care physician’s level of comfort. In fiscal year 2016, there were approximately 350,000 encounters with nephrology services other than dialysis.

Inpatient dialysis is available at 125 VA facilities and 74 VA facilities offer outpatient dialysis. Due to a limited capacity, the VA also relies on community providers for the delivery of maintenance dialysis to veterans. In 2013, the VA issued a national contract with 23 outpatient dialysis providers, using Medicare’s payment model as a base.

Veterans eligible for home dialysis receive services at either VA dialysis programs or via contracts with community providers. There are also seven regional VA kidney transplantation centers, offering transportation and indefinite immunosuppressive medications. VA enrollees are less likely to receive a kidney transplant than the general public, but are as likely as Medicare enrollees to be a kidney transplant recipient.

Out-of-pocket expenses for VA enrollees are limited. All virtual care is free, and copays for face-to-face care are nominal or waived. In addition, copays for monthly supplies of medications are capped or waivable.

In analyses of outcomes associated with CKD, trends are encouraging. The age-adjusted incidence rate of ESRD among veterans was 25% to 40% lower than that of nonveterans. The incidence rate of ESRD among veterans has seen a steady decline of 17% from 2009 through 2014.

While kidney care within the VA system meets or exceeds community care, there are opportunities for improvement. The VA has outlined strategies to achieve the agency’s goals for improvements:

  • Enhance veteran choice
  • Ensure health system capacity
  • Promote efficiency
  • Build sustainability

In summary, the authors said, “As the nation confronts a fundamental revision of healthcare policy, it is imperative that the current paradigm of CKD health services is scrutinized for opportunities to increase healthcare value. Recent analyses of veteran kidney outcomes indicate a benefit of the VA care model for those with CKD. However, because room for improvement exists, the current paradigm is not yet enough for those with CKD. As a fully integrated healthcare system, the VA is uniquely poised to develop, test, and identify emerging tools and models of care to advance additional reforms in kidney health services.

“Nearly a century ago, President Franklin D. Roosevelt urged the American people during the country’s worst economic crisis to embrace ‘bold, persistent experimentation’ to deliver a New Deal to the populace. Through bold and persistent experimentation in health service delivery, the VA can similarly help deliver a New Deal of kidney health opportunities to veterans and, by extension, to all citizens.”

Takeaway Points

  1. Authors employed at the Department of Veterans Affairs (VA) offer their perspective on opportunities to improve outcomes among veterans in the VA Health Administration system being treated for chronic kidney disease (CKD).
  2. Estimates of the incidence of CKD among the VA population are higher than in the general population; recent analyses have shown improvements in kidney health outcomes in patients in the VA.
  3. Kidney health services are delivered through the agency’s patient-aligned care team model; in fiscal year 2016, there were nearly 350,000 encounters for nephrology services (excluding dialysis).