Payment should support kidney protection before stage 3b

The most important lesson in PHTI’s assessment of virtual chronic kidney disease programs is a question of timing. Many of these programs are being asked to change the course of CKD after the health system has already missed years in which testing, diagnosis, and kidney-protective treatment could have had their greatest effect. 

That is the policy opportunity to address. 

CKD affects an estimated 37 million U.S. adults, and about 87 percent do not know they have it. The disease is usually silent while kidney damage accumulates behind the scenes. By the time a patient is referred to nephrology, enrolled in a kidney-focused program, or told to prepare for kidney failure, the most valuable management window may be narrowed..

Payment helps determine when the system pays attention. 

Today, kidney-specific accountability is often strongest when disease is advanced. That’s inconvenient, since at this point, complications are expensive and the need for dialysis is approaching. Earlier in the course of illness, the work is distributed across primary care, endocrinology, cardiology, nephrology, pharmacies, laboratories, health plans, and patients. Everyone touches part of the pathway. Too often, no one owns the whole trajectory.

Stage 3b, defined by an estimated glomerular filtration rate of 30 to 44, remains an important treatment window. A patient can still benefit from guideline-directed therapy, careful monitoring, medication management, and timely specialty care. Allowing stage 3b to become the first moment of sustained kidney management leaves too much of the earlier opportunity unused.

Did you know that earlier CKD may be visible in urine before it is obvious in a routine blood panel? 

Urine albumin can signal kidney damage even when eGFR is relatively preserved. That is why guidelines use both eGFR and urine albumin-to-creatinine ratio, or uACR, to detect CKD and estimate a patient’s kidney and cardiovascular risk. 

For people with diabetes, hypertension, cardiovascular disease, and other important risk factors, the practical opportunity begins with completing both tests, confirming an abnormal result, and placing the patient on the risk grid. That work can happen before symptoms, before stage 3b, and often before a nephrologist is involved.

Watch this 3-minute YouTube video explaining the KDIGO 2024 CKD Guideline for Detection of CKD:

Earlier management creates more runway. Blood pressure control, diabetes management, renin-angiotensin system inhibitors when indicated, SGLT2 inhibitors, and other kidney- and cardiovascular-protective therapies can slow progression for appropriate patients. Benefits differ by diagnosis and risk profile, and no therapy erases CKD. Starting the right care sooner gives patients more time to benefit and gives clinicians more time to adjust treatment safely.

PHTI evaluated eight virtual solutions that generally serve people with diagnosed, moderate-to-advanced CKD and those approaching kidney failure. The companies offer combinations of analytics, care coordination, patient education, clinical support, and value-based contracting. Some accept financial responsibility for total cost of care.

Available evidence did not show that these programs consistently increased use of kidney-protective medications, slowed loss of kidney function, reduced hospital use, or lowered total spending compared with usual care. The company-specific evidence base was thin, which limits confidence in broad claims in either direction.

PHTI did identify a meaningful benefit: more patients started dialysis in a planned outpatient setting instead of during an emergency hospitalization. That matters greatly to the patients who avoid a chaotic transition. Across the full population managed, however, the effect was small at about one additional planned start per 1,000 patients. The associated savings were less than 0.2 percent.

Those findings describe the reach of the intervention as much as the quality of the companies. A program concentrated near kidney failure can improve preparation for kidney replacement therapy. However, it cannot recover years lost before CKD was recognized, or reverse a long period in which indicated treatment was never started or sustained. Purchasers of virtual care solutions may want to ask when a program first encounters patients, which part of the disease trajectory it can influence, and whether its outcome claims match that window.

The breakdown comes from ordinary tasks that fail to connect. 

An eGFR is reported without a uACR. 

An abnormal result is never repeated. 

CKD appears on a problem list without a risk assessment or treatment plan. 

A prescription is written, then abandoned because of cost, side effects, or missing follow-up. 

Referral is deferred until kidney function has fallen further.

Fee-for-service payment reliably pays for visits and procedures. That’s pretty inconvenient, since much of kidney protection depends on work between visits: finding high-risk patients, closing a testing gap, reviewing results, titrating medication, checking safety labs, addressing medication affordability barriers to compliance, patient education and engagement, and making sure the next step occurs. Even in broader value-based arrangements, responsibility for those tasks can remain vague.

Kidney-specific payment models also reflect the same timing problem. Medicare’s Kidney Care Choices model, for example, creates accountability for people with stages 4 and 5 CKD and kidney failure. Its focus may improve late-stage care, such as ensuring more patients have the education needed to determine whether peritoneal dialysis is a better option and to help prevent “crashing” into dialysis, while the earlier years remain largely outside its center of gravity.

The incentive problem is therefore about timing and ownership. Payment must reach the clinicians and care teams positioned to act before stage 3b. It also must support a completed pathway rather than a collection of disconnected services. Finally, even when incentives are in place, practices must execute on care delivery transformation that enables guideline-concordant care to be followed.

(As always, not advice, only an illustrative example of what proactive, upstream identification and management of early CKD might look like.)

Both eGFR and uACR are completed. 

Abnormal findings are explained and confirmed as clinically appropriate. 

The patient is told the CKD stage, albuminuria category, overall risk, what it all means, and the name of the person or team responsible for follow-up.

The care plan should address blood pressure, diabetes where present, cardiovascular risk, medicines that can harm the kidneys, and kidney-protective treatment suited to the patient’s condition. 

It should include a monitoring schedule, support for adherence and affordability, and a clear threshold for nephrology involvement. Referral should be based on risk and clinical need, not used as the moment when basic kidney care finally begins.

For patients, the immediate question remains straightforward: Have I asked my PCP if I have any risk factors for early CKD and if so, Have I had both the blood test and the urine test that evaluate kidney health?

The policy goal should be a system in which patients do not need to know the questions or whether it applies to them to receive the right care (although with AI and interoperability advances, patients may increasingly share with their PCPs that they have self-identified their risk, and primary care should prepare for this).

Payment should reward the full kidney protection pathway during the years when clinicians have the most opportunity to influence it. Near-term measures can include things like completed risk-based testing, confirmation of abnormalities, documented risk stratification, appropriate medication use, monitoring, and successful follow-up. Longer-term evaluation might examine eGFR decline, cardiovascular events, avoidable hospitalizations, progression to kidney failure, and actual spending against credible comparison groups.

Digital infrastructure could be especially useful upstream, where much of the work involves finding omissions and making sure someone acts on them. EHR registries and population-health platforms can identify patients with diabetes, hypertension, cardiovascular disease, or other risk factors who are missing eGFR or uACR testing.

Clinical decision support can prompt testing, risk stratification, and appropriate treatment, while automated work queues help teams follow up on abnormal results.

Electronic nephrology consultations can give primary care clinicians specialist guidance without requiring every patient to transfer into nephrology care.

Pharmacists, nurses, and other on the care team can use telehealth, home blood-pressure data, and shared care plans to support medication management and follow-up. These capabilities do not replace clinical ownership. They make the kidney-protection pathway easier to complete and harder to abandon.

Maybe the more consequential test of virtual CKD care is whether it helps primary care teams complete this upstream pathway and produces measurable improvement before kidney disease becomes advanced. Managing a late-stage cohort against a benchmark answers a narrower question. Upstream programs will also require better evidence. Purchasers should expect transparent denominators, meaningful comparison groups, clearly defined entry points in the disease course, and outcomes that can be explained clinically.

PHTI is right to ask whether these programs improve outcomes and total cost of care. Its report also exposes a larger design flaw: the health system is placing substantial management infrastructure near the end of the disease course while basic kidney protection remains unreliable near the beginning.

A late-stage kidney disease program can organize care, reduce chaos, and help patients prepare for dialysis under better circumstances. It cannot return the years in which an unnoticed abnormal uACR, an unconfirmed decline in eGFR, or a treatment gap could have changed the patient’s trajectory. By stage 4, kidney care may be more visible and more expensive.

Payment policy decides which moments are treated as consequential. Early kidney protection belongs in primary care because that is where most patients with diabetes, hypertension, and cardiovascular risk already receive care. Yet assigning another responsibility to primary care without providing the capacity to carry it out will reproduce the gaps we already see. Payment should make primary care accountable for completing the early kidney-care pathway while funding the team and infrastructure required to do it. There should be little friction to identify patients at risk, systematically carry out reliable eGFR and uACR testing, and include nurses or pharmacists in the care team who close medication and follow-up gaps.

Nephrologists should be brought in according to a patient’s risk, rate of progression, diagnostic uncertainty, and treatment complexity. Here’s what they should not be: the first clinicians who recognize that someone’s kidney health requires sustained attention. A good goal is something like primary care-led, team-supported, nephrology-connected care, with responsibility clear enough that the patient never becomes the default coordinator.

Progress should be judged by how many fewer people reach advanced disease without ever having had their risk recognized, their urine tested, their results explained, or kidney-protective treatment offered and sustained. That standard would change what health plans buy, what vendors build, what primary care teams are equipped to do, and what patients experience long before they need a nephrologist.

The most successful CKD strategy may be almost invisible: a urine test ordered during routine care, an abnormal result that triggers action, a treatment plan that follows the patient, and kidney failure delayed or avoided years later. No dramatic rescue will show that this worked. The patient simply keeps more of the kidney function.

Before investing in another kidney solution, purchasers and policymakers should want to know when in the disease course it begins, and how much opportunity has already been lost by then. The years when a patient could have been identified, treated, and protected their kidneys are expensive ones to lose, and no one was accountable for making sure it happened.