Thread by @KatieKwonMD

Lessons from #RPA22 which just wrapped up in Dallas, a 🧵 1) Value-based care (#VBC) has injected a jolt of energy into the private practice sphere. Half the exhibitors on the convention floor were new since 2019. It was THE topic of conversation during the breaks - who are you

working with, have you signed up with anyone? The 3/25 deadline for KCE participation added to the frenzy, as did news of the Cricket-Interwell-Fresenius merger. Talks about VBC and the new payment models were well attended and garnered lots of questions and discussion.

2) The mandatory #ETC model is a dead letter, at least on the nephrologist side. For all but the big practices, the dollars at risk are too small, and the performance results too long delayed, to warrant making any changes. The dialysis companies have more $ at risk, but it was

clear that they have now made the operations tweaks they feel are warranted, and I think ETC will just play out with ever-dwindling numbers as more patients shift to MA plans. ETC has several design failures, but primary among them was that it did not center the nephrologists.

3) On the flip side, the optional #CKCC and #KCF models have attracted big private equity investment and garnered significant interest in private practice doctors. We will probably see more mergers from the companies seeking to partner with doctors to provide the data analytics

that are needed to succeed in these models. Does this spell the doom of the small and medium size practice? I do think that these practices are going to have to change in order to survive. It's no longer going to be acceptable to practice straight fee-for-service medicine in a

reactive fashion, and there's a big upfront and ongoing expense to instead target at-risk patients and seek to prevent adverse outcomes like crashing into dialysis. 4) Gatekeeping might become a big problem. One question-and-answer session at the VBC panel almost looked like Will

Smith and Chris Rock at the Oscars, as the LDOs and MDOs were grilled about new policies that prevent rival companies' care managers from entering the dialysis units. The rumor mill was hopping with reports of charges of $4K to credential each new provider.

This kind of anticompetitive restriction should not be tolerated - if we think our ESKD patients will benefit from the activation score process, then meeting patients where they are is the right thing to do. Add on the gatekeeping from #EMRs who put up roadblocks to the flow of

patient data and we could lose much of the promise that VBC holds to improve patient outcomes. 5) Each VBC company touted, among other things, their proprietary algorithms to identify patients needing targeted intervention. @JoeCoresh gave a great talk about clinical risk score

applications, and @john__r__lee talked about applied machine learning. Given well-publicized instances where AI wound up replicating society's worst biases, it's concerning to think of opaque algorithms being used to direct resources, without oversight to make sure bias isn't an

unintended consequence. This leads to 6) that VBC manel. Called out during the talk and afterwards online. Yes, must be better, and the previous point illustrates why. I was delighted to see the CMOs @Peralta_KHRC @SCrittendenMD and @DrShikaP all in attendance at the meeting

and hope to hear more from them as VBC evolves and matures. 7) Finally, and despite the concerns above, I came away from #RPA22 feeling the future of our profession is brighter. We have new therapeutics and will be leaders in changing how medicine is practiced, setting the

standard for all internists. Every practice I talked to is hiring. Let's all make sure the residents and medical students hear about the great opportunities in nephrology.