Chronic kidney disease (CKD) is increasingly being recognized as a global public health problem. The increasing prevalence and high cost of management contributes enormously to health expenditures. The treatment cost is estimated at $48 billion per year, consuming 6.7% of the total Medicare budget to care for less than 1% of the covered population in the US.¹ The global cost of CKD quadrupled in last 20 years and is expected to continue to increase in future.¹ Understanding the key cost drivers is key to developing strategies and interventions to bend the cost curve without compromising quality.

To study the prevalence, service utilization, and cost patterns of CKD, we conducted an analysis on a large commercial dataset with health insurance claims from major US health plans (approx. 3 million adult members) from 2015-2017. The prevalence of CKD for 2017 in this dataset was approximately 2.5%, and these members contributed to nearly 10% of the total health expenditures. The average PMPM (per member per month) cost of CKD members was almost 3.5 times the average PMPM cost for the overall population. The health expenditures of these members increased from 7.2% of the total health expenditures in 2015 to 9.7% in 2017. Table 1 shows the prevalence and health expenditure of members with CKD and its comparison with overall population.

Table 1: Prevalence and health expenditure of members with CKD from 2015 – 2017

* with respect to total members with claims

** with respect to total expenses of all claims

CKD is usually profiled into five stages based on severity of disease. CKD stages 1-3 are milder forms of disease and require less frequent interventions.⁶ CKD stages 4 and 5 require ongoing treatment on a regular basis. The analysis of members with CKD by stages showed that approximately 80% of members with CKD were found to have CKD in stages 1-3, and these members accounted for approximately 70% of the total health expenditures of all CKD members. Figure 1 shows the comparison of prevalence and health expenditure of CKD by stages over the years from the aforementioned dataset.

Figure 1: Prevalence and health expenditure of CKD by stages 1-5: 2015 – 2017

A common approach to managing chronic conditions is the identification and reduction of low value care services, which may not contribute much to treatment outcomes or modify the course of treatment. For example, the Journal of the American Medical Association (JAMA) identifies parathyroid hormone (PTH) measurement for patients with stage CKD 1-3 as low value care.²  The UK’s National Institute for Health & Care Excellence (NICE) guidelines also recommend against routine PTH testing in people with a GFR of 30 ml/min/1.73 m² or more (CKD 1-3).³ Research shows there is no evidentiary basis for an association between serum levels of parathyroid hormone and the risk of poor outcomes in early stages of chronic kidney disease, therefore PTH testing is considered as low value or wasteful in stages 1-3.⁴  We studied the prevalence of PTH testing services in the dataset and found that approximately 75% of all PTH testing in members with CKD were done in early stages of CKD (stage 1-3). Figure 2 shows the members with PTH testing from 2015 – 2017.

Figure 2: Members with PTH testing in CKD: 2015 – 2017

Further analysis to see what proportion of CKD members were receiving wasteful testing (referred as “testing prevalence”), showed that the higher proportion of wasteful testing was prevalent in younger CKD members. Members 18-40 years old had 28-36% wasteful testing prevalence, with this value gradually decreasing in the higher age groups. This same trend was seen in all the analysis years. Figure 3 shows the trend in wasteful PTH testing by age groups from 2015 – 2017 from our analysis.

Figure 3: Trend of wasteful PTH testing by age groups: 2015 – 2017

Our cost analysis also showed an increasing trend in the total cost for wasteful PTH testing over the years. Figure 4 shows the cost of wasteful PTH testing in CKD members over the yearOur analysis also showed an increasing trend in the total cost for wasteful PTH testing over the years. The cost of wasteful PTH testing in CKD members increased from $176k in 2015 to $186k in 2016 and $189k in 2017. The cost saving opportunity by avoiding these wasteful PTH testing was approximately $ 0.5 per member per month.

It is important to note that claims data alone allows only an approximate identification of low value care services in CKD members. It may be appropriate to do PTH testing in early stages of CKD in certain situations, such as members with hypercalcemia or on dialysis, therefore these members have been excluded from the analysis of wasteful PTH testing.

This analysis confirmed the high prevalence of PTH testing, a low value care in early stage of CKD.  This is just one example of how analysis of low value care can help identify opportunities to address avoidable costs and achieve optimal clinical care.  A separate study on low value care summarized in Health Affairs reported that the total cost for the low and very-low cost low-value services was nearly twice as much as the total cost of high and very-high cost low-value services.⁵ Targeting these low cost and high volume services for reduction of wasteful health expenditures can have a sizable impact on reducing unnecessary health care spending. “Less is More” is an important concept in combating the overuse of medical services to help reduce the harm caused by overuse, optimize cost, and maybe even improve health.

References:

1. Damien P, Lanham H, Parthasarathy M, Shah N. Assessing key cost drivers associated with caring for chronic kidney disease patients. BMC Health Services Research, vol. 16, no.1, 2016.
2. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program: Aaron L. Schwartz, P. Michael E. Chernew, Bruce E. Landon, J. Michael McWilliams. JAMA Intern Med. 2015;175(11):1815-1825.
3. Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care (CG182): NICE Clinical Guidelines, No. 182; 2014 July. https://www.nice.org.uk/donotdo/do-not-routinely-measure-calcium-phosphate-parathyroid-hormone-pth-andvitamin-d-levels-in-people-with-a-gfr-of-30-mlmin173-m2-or-more-gfr-category-g1-g2-or-g3
4. Palmer S, Hayen A, Macaskill P, et al. Serum Levels of Phosphorus, Parathyroid Hormone, and Calcium and Risks of Death and Cardiovascular Disease in Individuals With Chronic Kidney Disease. A Systematic Review and Meta-analysis. JAMA. 2011;305(11):1119-1127.
5. Mafi J, Russell K, Dachary M, et al. Low-Cost, High-Volume Health Services Contribute The Most To Unnecessary Health Spending. https://doi.org/10.1377/hlthaff.2017.0385Stages of Chronic Kidney Disease (CKD), American Kidney Fund (AKF). https://www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/stages-of-chronic-kidney-disease/