Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value
Authors: Brady Brian M. , Ragavan Meera V. , Simon Melora , Chertow Glenn M. , Milstein Arnold 
Published: November 2019

Significance Statement
As federal and private payers move toward value-based payment, the authors sought to identify attributes of nephrology care associated with payer-defined value. The authors conducted site visits at United States nephrology practices ranking near the top or ranking near the 50th percentile on measures of quality and total cost of care commonly used by payers. They identified 12 care attributes common in highly ranked nephrology practices that fell into five themes: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. A panel of nephrologists predicted that four value-based practices may be easiest to transfer to less-favorably ranked peers: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact. Findings from this exploratory study may serve as a starting point for United States nephrologists who face increasingly value-sensitive payers and patients.

Background
Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored.

Methods
Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices.

Results
Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact.

Conclusions
Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.