Chronic kidney disease (CKD) is surprisingly common and often goes undiagnosed until later stages, when treatment options are limited. It is also a major driver of healthcare spending, particularly in Medicare. Given the high costs associated with dialysis (>$100,000 per patient) and transplant, substantial focus has gone into managing patients with late-stage CKD as they transition into kidney failure, including by supporting planned transitions to dialysis.

Unlike other solution categories PHTI has assessed, virtual solutions for CKD management take on population-level risk for patients’ total cost of care. For instance, a company may be responsible for all members in a given Medicare Advantage plan who are diagnosed with CKD within a geographic region. These companies then work with nephrology practices to implement value-based care arrangements and support enhanced care management and education for their patients. Ideally, companies would work to slow disease progression by ensuring patients are prescribed effective medications to slow kidney damage—which, in turn, would reduce spending. Unfortunately, that is not what is happening.

Our evaluation found no consistent evidence that virtual CKD management solutions slow disease progression or reduce overall healthcare spending across the population of covered patients. Even more surprising, despite tremendous capital investment, almost none of these companies have generated any clinical or economic evidence. In Traditional Medicare, the Kidney Care Choices model—launched in 2022—is a large-scale demonstration that has found no reductions in healthcare spending for patients with CKD who were covered in the model compared with those who were not, and incentive payments to participating nephrology practices added to overall Medicare spending.

The challenge is that payment models focus too much on late-stage CKD. The better opportunity to drive change is upstream: by increasing early screening and diagnosis and by focusing on medication management, most patients could avoid progressing to end-stage kidney disease altogether. Yet, because these companies are responsible only for diagnosed patients and work primarily with nephrologists, they have neither the incentive nor the access to improve CKD diagnosis in primary care settings. And because many patients go undiagnosed until the disease is advanced, these companies have limited opportunity to slow disease progression. The best they can do for most patients is help them avoid crashing into dialysis. That is a real improvement, but one that helps too few patients to meaningfully reduce system spending.

This evidence points to a clear path forward: change what we pay for in CKD care and pay for it at the level of the individual patient. Health plans and CMS should prioritize earlier diagnosis and focus on getting patients on the right medications—many of them proven, generic, and underprescribed. We have the clinical tools available. Now we need contracting and payment models that reward early detection, rather than late-stage interventions. With the right incentives, it is possible to close this gap between guideline-recommended care and what patients actually receive.