Challenging the Status Quo of Kidney Care: A Conversation with Strive Health

Chronic kidney disease affects more than one in seven American adults or about 37 million people. When exacerbating factors such as diabetes, high blood pressure, repeated infections or injuries, drug and tobacco use are not managed well, the risk of chronic kidney disease (CKD) advancing to end stage kidney disease (ESKD) significantly increases. With each CKD stage progression, cost to US health plans increases exponentially. Medicare alone spends an estimated $130 billion on kidney care, including nearly $30 billion to provide dialysis to 554,000 Americans with kidney failure. Additionally, patients with CKD, even in early disease stages, carry a disproportionate burden of cardiovascular morbidity, mortality, healthcare utilization, and costs.

The high costs and high health care utilization associated with CKD combined with the prevalence of the disease underscore the need to identify interventions and strategies that reduce costs and utilization, prevent or slow disease progression, and address contributing factors which exacerbate the disease to improve patient outcomes.

Identification of these drivers of costs is important for shaping health policy decisions as it allows for more accurate attribution of health care utilization and intervention for other determinants of health within this population. If CKD is detected early, treatment is initiated, and other determinants of health are addressed, it may slow the decline in kidney function, delay kidney failure and potentially offset the downstream impacts of this disease.

Continuing our series on moving care into a patient’s home, we spoke with Alice Wei, M.D. and Senior Medical Director of Dialysis at Strive Health, to learn more about their unique care model as well as how providing care in a patient’s home environment is prime to support whole-person care.

What is Strive Health and how is this model different?

Strive Health is the nation’s leader in value-based kidney care and partner of choice for innovative healthcare payors and providers. Strive's core solutions include Population Health, Strive Care Partners™ (a value-based nephrology platform) and Complete Dialysis. Using a unique combination of high-touch care teams, predictive analytics, advanced technology, seamless integration with local providers and next-generation dialysis services, Strive forms an integrated care delivery system that supports the entire patient journey from chronic kidney disease to end-stage kidney disease. Strive partners with commercial and Medicare Advantage payors, Medicare, health systems and physicians through flexible value-based payment arrangements, including risk-based programs. Strive’s case management and population health programs are accredited by the National Committee for Quality Assurance (NCQA), and its technology platform, CareMultiplier™, is certified by HITRUST.

As for how we’re different, it really starts with our distinctive culture. We believe a company is only as good as the culture it cultivates. It makes the difference between people who are just clocking in vs. a company like Strive where people are mission-driven. We are here for a purpose — not just among ourselves, but also in alignment with our partners. We choose our partners carefully and seek out partners that are aligned in our mission to completely reinvent kidney care. That ultimately sets us apart.

That’s why forward-thinking companies, such as Regence, Bon Secours Mercy Health and NANI, chose us as a partner. They recognize that the company culture we built is substantially different from our competition. We optimize our partner’s experience because it is a foundation for an optimal patient experience. Our clinicians build relationships and trust with patients and that significantly drives better health outcomes. We start with the patient and end with the patient. That is our true North Star.

Compared to traditional kidney care models, have you seen evidence of improved patient outcomes or patient satisfaction with this model?

Our data shows that we have tremendous impact on improving patient outcomes. We have reduced hospitalizations, increased home modality adoption, increased transplantation and reduced total cost of care — in double-digit percentage points. That’s remarkable, considering Strive was founded just around four years ago.

We also do extraordinarily well with our patient satisfaction surveys. The survey results point to the level of competency of our clinicians and the trust patients have in them. But we are not satisfied with positive outcomes and surveys. We are always striving to do even better for our patients. That points back to our culture. We want what’s best for our patients, partners and providers. The program is only as good as the least happy stakeholder. That's what's so great about value-based care (VBC) models. In the traditional fee-for-service models, payors were pitted against providers and patients. In the new VBC world, keeping patients healthy translates to cost savings and better outcomes for all stakeholders.

The patient-physician relationship is very important. Strive is here to help that relationship, to fill in the gaps and increase the capacity of that physician. We aren’t here to supplant the provider or take over the care for the patient. If we can alleviate the administrative burden and care coordination that’s left to the provider and allow them to focus on clinical care, that ultimately serves the patient.

How do home dialysis and mobile visit services compare to traditional services performed in brick and mortar locations in terms of both quality and cost?

In terms of disease management more broadly, it’s not a fair comparison. Home care is a necessary service for many people. We have people who are home bound or not as mobile or at increased risk due to being immunocompromised and interacting with other patients is not ideal for them. It’s not a surrogate for brick-and-mortar care; it’s a supplemental service that’s critical for some.

A lot of competition is relying on telehealth and they’re calling that home service because the patient stays home. They aren’t the same thing. For Strive Health, home care means that our clinicians enter a patient’s home for an in-person visit. They get a sense of their lifestyle, their home environment and many other micro details. These are not things you can be privy to in a brick-and-mortar setting or through a two-dimensional screen.

The cost is in the additional time it takes for clinicians to visit patients at home. If you’re sitting in an office as a physician or a nurse, you can reach more patients. But we are committed to home visits because it is a matter of increasing access to care, and giving our clinicians an additional layer of insight into our patients’ lives. There will be long term cost savings associated with those benefits.

For people who need dialysis, dialyzing at home can be a better option. There is much greater flexibility in their schedule and ability to resume their lifestyle before the diagnosis of kidney failure. The time spent traveling to and from a brick and mortar dialysis clinic, waiting for your chair and machine to be ready, waiting for your access to be readied is equivalent to a part time job. Patients are better served by using this time to live their life.

There are great cost benefits too to home dialysis. In 2018, Medicare spent on average $15,000 less per beneficiary per year on patients on peritoneal dialysis compared to patients on hemodialysis. For providers, home dialysis costs about $40 less per treatment to deliver compared to in-center.

What technological advancements are coming that may further improve delivery of kidney care in the home?

Remote patient monitoring is a big one that is going to continue to expand, especially continuous remote patient monitoring. The technological advancements allow for smaller and less intrusive wearable devices that monitor patients continuously and can provide data feeds in real time. What can be monitored by these devices has also dramatically widened the field.

It used to be that if a patient came to see a physician about high blood pressure, we would run a test at that one moment in time and we would extrapolate the data to mean a whole lot about the patient’s health. But what if the patient was experiencing “white coat hypertension” — in other words, they were just nervous about coming to the doctor’s office. Their blood pressure may have been higher in that moment, but not reflective of the holistic picture.

With continuous remote monitoring, the patient wears a device they can forget about and their blood pressure is being taken constantly. The patient and their care team get access to a wealth of information to better assess the meaning behind the numbers and the impact of any intervention taken. This will lead to better patient and provider experience, better outcomes that then translates to cost savings.

Continuous glucose monitoring is another big one for diabetics. Unfortunately, not all payors will pay for them, which is tragic. The amount of insightful data and the quality of that insight from continuous remote monitoring benefits all stakeholders in healthcare.

What barriers exist to growth and scale of this type of care model?

1. Getting providers to understand value-based care. It requires a mind shift to accommodate a new paradigm of care delivery. Providers need to start thinking about prevention, utilization and being accountable to outcomes. Medicare has made changes here and there to incentivize outcomes, but it’s been fragmented. This new value-based care paradigm is a complete shift from fee for service. Our entire healthcare system is predicated on acute care delivery and Strive is trying to change that. We need to think in terms of how we keep people healthy.

2. Patient knowledge that this is an option. People with kidney disease often have multiple co-morbidities. They see so many sub-specialty physicians and they are bombarded with so much information that it can be hard to know what options they have. Usually the primary care doctor has the responsibility of preventative maintenance while also coordinating sub-specialties. Our Kidney HeroesTM are the coordinating force for both providers and patients. They take the administrative burden off of the doctors so they can focus on patient care. The Kidney HeroesTM also journey alongside the patient to help them connect all the dots, provide education and empower them in their health decisions.

3. Workforce: There’s been a mass exodus of healthcare workers in the past several years and the pandemic only accelerated this. There are nursing and physician shortages everywhere. Yet we remain selective with our hiring at Strive. We want the best workforce and that’s why we are proactive about ensuring a robust training program. We are invested and committed to our Strivers’ continuous training and we are excited to train the next generation of care providers.

4. Limitations of technology and data: Strive has an outstanding technology platform. But some data sets can be a challenge. We have found that claims data from CMS can underestimate the stage of kidney disease by around 20%. If the disease staging is incorrect, that affects prognostication and we could miss our window to impact a patient’s disease trajectory. It’s a small window. Operational efficiencies are also lost if resources are not allocated appropriately. We’ve found some payors and healthcare systems also have antiquated technology platforms that limit their ability to produce accurate metrics or integrate with third party platforms. Investments in tech just doesn’t get prioritized in the traditional FFS system that is dependent on volume of services.

Are there policies or legislative actions that could advance adoption of care at home models or conversely, restrict or hinder adoption? Are there regulatory actions to ensure quality care is provided?

Using dialysis as a means of illustration, in order to transition a patient to dialysis at home, it requires a tremendous amount of resources up front. It requires education for the patient and that the patient absorb a lot during a typically traumatic time.

The small incentive payments that CMS has in place right now are not enough to offset some of that initial resource-intensive period. In CMS’ Conditions for Coverage. there are not home dialysis-specific policies that are meant for patients at home. We’re extrapolating policies meant for in-center for the home setting. It’s not practical. What you require in-center isn’t necessarily needed at home.

Strive is partnered with the National Kidney Foundation, the American Society of Nephrology, Outset Medical, CVS Kidney Care and other innovative companies in a consortium called Innovate Kidney Care. It’s focused on public policies for greater access to home dialysis.

We have a shortage of nurses, especially dialysis nurses and even more especially home-trained dialysis nurses. That’s a bottleneck to patients getting on home dialysis. Physicians are also coming out of nephrology training without much education or exposure to home dialysis. More must be done amongst fellowship programs to better prepare nephrologists and surgeons. There are areas of the country where there isn’t anyone with the skills to place and maintain a catheter for peritoneal dialysis.

Policy can set the framework on which you can build successful programs. We need to start looking at the existing policies and updating them to incentivize quality of care and access to that care.

There are many environmental, medical, and social factors that contribute to the progression and severity of chronic kidney disease. Notably, communities of color and those with lower socioeconomic means suffer the greatest impacts. How does the Strive Health model address social determinants of health and these other risk factors?

We know that between 30-50% of a patient outcomes are attributable to social determinants of health. It is paramount that a care delivery model focus on SDOH.

At Strive, we focus on the things we can impact: whether a patient smokes or drinks alcohol in excess, whether a patient gets physical activity, their diet, sleep and other lifestyle factors. We rely on the Kidney HeroesTM team to take an interdisciplinary approach. It’s not enough to tell a patient to stop smoking. We support them to change their behaviors.

We do it more effectively because of the relationships we build not only with the patient, but also with their family members, communities and their entire, extended care team. We use coaching and mentoring to support them throughout their transition to a healthier lifestyle.

How does the Strive Health model address health equity? What do home-based care services offer to communities who have been historically underserved?

People of a lower socioeconomic state or living in rural settings suffer worse health outcomes. There are also disparities across different racial, ethnic, gender and sexual orientation groups. These disparities have been estimated to cost billions of dollars. So aside from a moral obligation, there is also a compelling business case to address this.

Addressing health equity is not just whether or not there are enough culturally sensitive physicians or hospitals and clinics in a community. It’s also whether or not the patient has transportation to and from those care centers, has the information they need — in a language they know — to navigate and understand their health plans and know what services are available to them. When we offer home services, we can break many of those barriers. We also free up acute care settings for those needing truly acute care because the emergency room is the first place of contact for healthcare for many of the underserved population.

At Strive we see ourselves as advocates of both patients, physicians and health payors. We ensure everyone has the right education to take full advantage of quality healthcare, including at-home services.