How Lab Values Can Close the Gap Between Patients With Undiagnosed and Under-Staged Chronic Kidney Disease

Chronic kidney disease (CKD) is an insidious condition with devastating consequences when detected and treated too late. While primary care physicians usually make the initial diagnosis, regular screening is not routine for the general population, and the symptoms are nonspecific, making them difficult to detect.

As a result, CKD is commonly underdiagnosed, which delays treatment, harming patients and increasing the cost of care for them and their health plans. Most health plans cannot support patients and physicians in detecting and managing CKD because they don't know that a patient has the disease until there is a claim for CKD services.

However, a pilot program in North Carolina and a similar study in South Carolina have shown the that using lab value analytics to improve the diagnosis and management of CKD can unlock health plan savings.

Deadly and Expensive

CKD is called a silent killer because the symptoms are subtle, and the kidneys' ability to compensate for lost function can mask the disease until it is far along. As a result, many patients are unaware they have CKD until it has progressed to later stages. About 37 million US adults are estimated to have CKD, and most are undiagnosed. Ninety percent of people with the disease are not aware they have it. Consequently, 9 of 10 patients are diagnosed at Stage 3 or later. Health plans, even those with kidney disease programs, frequently underestimate the prevalence of members with CKD.

CKD can progress to end-stage renal disease (ESRD), which is fatal without artificial filtering (dialysis) or a kidney transplant. Treatment and lifestyle changes can slow CKD progression but not reverse it.

Treating CKD is expensive. According to the US Renal Data System 2022 Data Report, Medicare spending for CKD patients ages 66 or older exceeded $75 billion in 2020, representing 25.2% of Medicare spending in this age group. (CKD, in its final stages, makes individuals eligible for Medicare regardless of age). Medicare-related spending for those with ESRD totaled $50.8 billion in 2020—the more advanced the disease, the more expensive the treatment.

The cost for commercial carriers is high, as well. A 2017 study found that for commercial carriers, the average per-patient annual cost accelerates from $7,357 for those without CKD to $121,948 for those with ESRD without dialysis. A 2023 global study found that direct yearly costs associated with CKD management rose by an average of 4 upon progression from stage G3a to G5.

A New Detection Method

Many health plans have programs to identify CKD patients but rely solely on analyzing claims data. However, that method is inadequate because of coding issues, the lag between patient care, and the time claims are submitted and available for analysis. Therefore, early identification is limited as claims data does not represent the complete picture.

To detect and treat CKD earlier, 2 regional Blues plans recently investigated whether adding lab value insights to the analysis could help identify the disease earlier and stratify their member population at risk for or undiagnosed with CKD. The health plans also wanted to check whether they accurately estimated the number of members with CKD and their disease stages.

Both plans worked with their same lab benefits management (LBM) partner, which had access to the insurers' claims data and lab result values from multiple tests, such as creatinine, estimated glomerular filtration rate, urine albumin creatinine ratio, and A1c. The LBM applied its proprietary analytic model and algorithms to the data to identify and stratify high-risk CKD patients across all stages. Rather than rely on single test results, the LBM took a longitudinal view of multiple labs, looking for trends that could indicate CKD.

The results surprised the plans.

Based on its claims data, one of the plans had previously identified 2,148 commercial members with Stage 4/5 CKD and ESRD. However, the LBM identified an additional 4,430 members who were likely to have undiagnosed Stage 4/5 CKD and ESRD, potentially more than tripling the number of patients with advanced CKD.

For this pilot, the LBM, using only 5% of available members' lab data, identified more than 11,000 members (9%) who could be at some stage of CKD. Of the undiagnosed population, 3.4% were diagnosed and staged for CKD, with 25% of them being in Stages 4 to 5, with severe kidney damage. The LBM analysis also found different rates of CKD diagnosis among provider groups, information the plans can share with them to improve detection rates.

Before the new LBM program, the second pilot had identified approximately 16% of its members with Stage 1 to 5 CKD. The plan estimated more than half of those in Stages 3 to 5 had no diagnosis of CKD in lab claims.

Through the LBM analysis, the second plan will use lab values to identify members at risk for CKD or in active CKD progression and assign an engagement scoring model for each member at each stage. The plan will use this information to improve patient engagement through various strategies to decrease the cost of care, increase patient duration in their current stage, and slow disease progression.

The Benefits of Early Detection

Officials from both plans said the findings have caused them to reassess the prevalence of CKD among their members and how they address the disease. One of the health plans is expanding its contracted, third-party program based on the first pilot.

Its counterpart plans to reward physicians whose patients, in aggregate, improve their engagement by sharing the savings realized through the program.

The insurers have shared the results with members' primary care physicians and suggested they conduct tests to confirm a CKD diagnosis. Subsequently diagnosed and staged members are referred to specialists and urged to enroll in the insurers' programs to treat the disease. Value-based care providers incentivized to detect and treat conditions earlier have been particularly open to the information and working with their patients according to the plans.

Both plans praised the LBM for providing actionable insights, not just data, and strengthening their relationships with their members' providers.

In addition to increased and earlier identification of patients, the LBM can perform other services as part of the CKD program, including:

• Analysis of patient adherence to recommended care, including identification of high- and low-engagement members
• Provider performance reporting, including provider and practice scorecards of disease progression, patient engagement, value-based care, and quality metrics

Both plans are exploring the possibility of using lab values to detect other diseases, including cancer and diabetes.

Conclusion

The pilot results from both plans indicate that analyzing lab-based values lets health plans identify potential CKD patients earlier, confirm the diagnosis, and refer them to the appropriate care. The earlier patients are identified and staged, the sooner they and their providers can act to slow the progression of the disease. This will result in patients living longer, healthier lives and reducing their care costs.

About the Author

Julie Schulz, MD, MPH is the VP of product at Avalon Healthcare Solutions. Dr Shultz is responsible for the product strategy and product go to market execution of Avalon’s Lab Insights solutions. She is a physician executive and product leader with experience building and leading health care decision support, analytics, and B2C products. Dr Shultz has a specific focus in value-based care, women's health, medical device & pharma, and patient & physician engagement.