Health equity in kidney disease management

Advancing health equity within kidney disease management is both a moral and business imperative

Communities of color are disproportionately impacted by the disease, from higher diagnosis rates and dialysis utilization that far outpaces their proportion of the overall population to less access to transplant waitlists and evaluations.¹ Black patients tend to wait a year longer on such lists than their white counterparts, a disparity that almost certainly contributes to the lower graft survival post-transplant for Black patients.² The risk of kidney failure, too, is anything but uniform. Hispanics and Latinos are 1.³ times more likely to experience kidney failure than their white counterparts. For Black patients, the heightened risk is nearly 4 times greater.³ And rising rates of kidney disease only add urgency to the clear need for health plans to take action. If current trends continue apace, kidney disease is estimated to be the fifth leading cause of deaths globally by 2040.⁴ Here are 5 strategies to slow the disease’s ascent up the list and create more equitable access, treatment and outcomes for all.

1. Take aim at race adjustments

eGFR (estimated glomerula filtration rates), a gold standard metric of kidney function, and uACR (urine albumin-creatine ration) are calculated based on the amount of creatinine in a patient’s blood. Historically, that math has been adjusted for Black patients, a practice rooted in early research that suggested Black people may naturally have higher creatinine levels.⁵ Interpreting creatine levels through a race-based lens has meant that many Black patients who might otherwise been flagged as having kidney issues early on received a delayed diagnosis, potentially robbing them of the opportunity to make lifestyle tweaks that could slow the condition’s progress and delaying transplant referrals, which can increase wait times and reduce a patient’s graft survival rate.

As kidney care has evolved — and science has abandoned the misguided notion that race is biological — the race-based eGFR calculation has increasingly fallen out of favor. In 2021, the National Kidney Foundation, along with the American Society of Nephrology, announced it was developing a new, non-race-based calculation to be used for patients of all ethnic backgrounds.⁶ In addition, last summer the Organ Procurement and Transplantation Network decreed that all transplant-performing hospitals in the country must immediately cease using race-based calculations.⁷

The takeaway for health care plans? There’s no time to waste in ensuring that every provider under the plan’s purview is now adhering to these updated eGFR and uACR calculation protocols. Not only is doing so the most medically sound and equity-minded approach, it also has been shown to have an enormously positive impact on patient care. An October study in PLoS One found that the removal of race adjustments in kidney diagnosis both reduced bias and improved accuracy and precision.⁸

2. Bolster member navigation and personalized engagement

Providing individualized support and culturally tailored interventions can be a game-changer in the quest to equitably guide patients through their kidney disease journey. Not only does this approach amplify messaging around vital screenings and comprehensive care, it can also serve as a guiding force when the provider-patient relationship is disrupted or simple issues with health literacy or data fluency inhibit follow-through on seeing a specialist.

What might direct member engagement around kidney disease look like? Perhaps leaving accessible health-related literature at local community centers, gathering sites and places of worship; partnering with community leaders to raise awareness of common signs, symptoms and comorbidities of kidney disease; or hosting culturally competent health screening events. Another powerful tactic is embedding nephrologists or other care ambassadors within local health clinics to close the specialist care gap and ensure a swifter, more seamless transition between care teams.

Or it might mean working with employers to engage harder-to-reach populations through workplace communications. A small study in the Journal of Occupational and Environmental Medicine found that workplace interventions increase kidney disease treatment adherence. The participants who received targeted outreach in their workplace were 2 times more likely than the control group to visit an outpatient nephrologist.⁹

3. Lean into value-based models of care

Value-based care models are gaining momentum around kidney disease management — and for good reason. McKinsey, which notes that nephrology in particular has been at the forefront of value-based program adoption, found that health systems adopting a value-based model for kidney care “report substantial reductions in hospital admissions, readmissions, and dialysis crashes.”¹⁰ Considering that such high-cost, high-stakes acute episodes as dialysis crashes disproportionately impact patients of color, those reductions are also a win for health equity.

Health plans and federal agencies alike are taking notice. The Advancing American Kidney Health initiative introduced 2 new value-based payment models recently, the mandatory ESRD Treatment Choices Model in 2021 and the voluntary Kidney Care Choices Model in 2022. Several state Medicaid agencies have also begun incentivizing providers to include population health efforts in their kidney disease management, and also tying payments to social needs-based interventions.¹¹

Embracing value-based care models doesn’t have to mean eschewing fee-for-service pricing across the entire portfolio overnight. Rather, health plans may want to consider implementing targeted value-based condition management programs, aimed specifically at costly and complex conditions such as kidney disease. Then, partner with providers to help bolster their awareness and adoption of such programs, to increase utilization and ROI.

4. Use data analytics to identify at-risk members earlier

Kidney disease is so dangerous, in part, because it can present with few or no symptoms. Patients may not realize they have the disease until it’s progressed enough to trigger a life-threatening acute care episode, at which point treatment options become limited and prognoses worsen. As many as 9 in 10 people with kidney disease don’t know they have it.¹²

Data analytics can help illuminate what might otherwise go undetected until it’s too late. When machine learning algorithms are applied to vast reams of member health data, technology can swiftly surface which individual members may be at higher risk for kidney disease. Perhaps even more impactful, though, is that such programs can also discern which of those members likely already has the condition and the stage at which their disease has progressed. One such machine learning program, developed by researchers at Columbia University, scans electronic health records for potentially overlooked indicators of kidney disease — and has been found to be nearly as accurate (95%) at determining the presence of kidney disease as experienced nephrologists.¹³

While powerful analytics can be game-changing for any population, they may be even more potent for those groups at highest risk of kidney disease who are also juggling several comorbidities or have fragmented health care. Research suggests that providers, who often under-screen for kidney health even in high-risk groups, tend to spend even less time focused on kidney care when patients have multiple other health issues in play.

5. Tailor efforts to promote in-home dialysis

Many members likely don’t know that dialysis needn’t take place in a clinical setting — in fact, it can often be conducted right in the privacy of their own home. With in-clinic dialysis lasting up to 5 hours, with 3 sessions each week, often for several years, an in-home alternative saves patients time and energy. But it also removes any potential social determinants of health (SDOH) barriers — from lack of transportation or childcare to needing to take time off work for treatments — that can make adherence so hard for vulnerable populations.

Yet here, too, health disparities interfere. Black and Latino patients are far less likely than white patients to be treated with in-home dialysis. And research suggests that systemic bias and social barriers are clear contributors to those lower rates, alongside geographic, demographic and clinical factors.¹⁴

Greater awareness and front-line promotion can bolster adoption rates, improving quality of life for patients and helping plans curb their rising dialysis spend. Other tactics on health plan radars include reimbursing patients for days when training requires missing work, increasing telehealth and home visits, providing transportation assistance, and providing coverage for a trained caregiver to oversee in-home dialysis.

Such efforts also align plans with the Biden Administration’s goal of increasing equitable access to in-home dialysis. The Advancing American Kidney Health Executive Order of 2019 set a target that, by 2025, 80% of patients with incident kidney failure should be started on in-home dialysis or receive a kidney transplant.

While there’s no single solution that will solve the entrenched racial disparities in kidney disease management, health plan leaders can affect real change through a constellation of initiatives and efforts. What matters less, perhaps, than perfecting any singular strategy is to simply take action — then measure results, evaluate outcomes and iterate on those strategies. 

Learn more about Optum Kidney Solutions.

1. American Journal of Nephrology. Health disparities in kidney transplantation for African Americans. 2017.
2. American Journal of Transplantation. OPTN/SRTR 2018 Annual Data Report: Kidney. January 2020.
3. National Kidney Foundation. Health disparities.
4. Nature Reviews Nephrology. Sustainable development goals relevant to kidney health: an update on progress. November 2020.
5. National Kidney Foundation. Understanding African American and non-African American eGFR laboratory results.
6. National Kidney Foundation. NKF and ASN release new way to diagnose kidney diseases. Accessed January 4, 2023.
7. Organ Procurement and Transplantation Network. Frequently asked questions about implementation of the requirement for race-neutral eGFR calculations.
8. Umeukeje, Ebele M., et al. “Systematic Review of International Studies Evaluating MDRD And CKD-EPI Estimated Glomerular Filtration Rate (eGFR) Equations in Black Adults.” PLOS One, 17,10 (2022).
9. Iakoubova, Olga A et al. Workplace outreach program improves management of chronic kidney disease. Journal of Occupational and Environmental Medicine vol. 64,6 (2022): 482-487.
10. McKinsey & Company. Investing in the new era of value-based care. Accessed January 4, 2023.
11. Health Affairs. Health equity should be a key value in value-based payment and delivery reform.
12. Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2021.
13. Shang, N., Khan, A., Polubriaginof, F. et al. Medical records-based chronic kidney disease phenotype for clinical care and “big data” observational and genetic studies. npj Digital Medicine. 4,70 (2021).
14. Journal of the American Society of Nephrology. Racial and ethnic disparities in home dialysis use in the United States: Barriers and solutions. July 2022.