1. Further leaning into the point about risk stratifying the population until, in the words of Tina Fey, "everybody hates it:" G3a CKD with A1 albuminuria is a very different patient from one with G3a CKD and A3 albuminuria. Every specialty is going to have their own model for dealing with CKD/CKM (PCP, NKF's CKDintercept, American Heart Association will claim cardiology, etc.). We will get better (hopefully) at identifying where patients are best managed, whether PCP or specialty care, and that will inform the ROI on care navigation from policy, operations, and health system standpoints and help us deal with that old chesnut of heterogeneity in the CKD population, which is so endlessly maddening to the good folks paying for all of this.
2. As usual (and why does he really need any help?) the devil is in the details on the PIN codes. It is great to have them and incident-to billing is an operational challenge, to say the least, and that is subject to the same opportunity cost as we see with KDE of, "is this really worth my time?" That would be the argument for the ChenMed model of working with care navigation through a total cost of care model where optimally, navigation and faciliation become part of the care model. On the other hand, having a traditional fee-for-service model makes it much easier to try out PIN and see what works, especially with a mixed short-term ROI. So, as with most things, chicken or egg, etc.
3. I think there are many opportunities to improve care navigation with community health workers, particularly in settings where cultural concordance is very important (like dialysis). There, the reimbursement issues are more concrete but also more solvable. For example, the nephrologist billing the MCP can initiate services and then a CHW can step in and be paid. Similarly, an ESRD Network can hypothetically initiate services, but it would have to be under an NPI, etc.
I personally have not but would be interested to see who is using them in CKD. I think there is definitely an opportunity to utilize them in at least advanced CKD (stage 5) and those with CHF and CKD.
Tim, great article as always! The road to optimizing CKD care is a long one but we will get there. I am a firm believer in that the change has to come from the practice culture level to be impactful. Hopefully some of these novel codes will help drive that change.
Thanks, Jay! Appreciate you reading and I hope so, too. I know there are other billable services that have clinical and economic benefits but remain vastly underused (e.g. MNT, KDE). Have you seen / heard these PIN codes being used much yet?
![Signals From [Space]](https://substackcdn.com/image/fetch/w_80,h_80,c_fill,f_webp,q_auto:good,fl_progressive:steep,g_auto/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F55686857-6b99-45a6-ac0f-09c9f023f2a0_500x500.png)
![Signals From [Space]](https://substackcdn.com/image/fetch/w_36,h_36,c_fill,f_webp,q_auto:good,fl_progressive:steep,g_auto/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F55686857-6b99-45a6-ac0f-09c9f023f2a0_500x500.png)
![Signals From [Space]](https://substackcdn.com/image/fetch/e_trim:10:white/e_trim:10:transparent/h_72,c_limit,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F4d588ac1-7fac-4bd4-829d-fc7b4e8f1326_1512x288.png)
Another great analysis, Tim! A few thoughts:
1. Further leaning into the point about risk stratifying the population until, in the words of Tina Fey, "everybody hates it:" G3a CKD with A1 albuminuria is a very different patient from one with G3a CKD and A3 albuminuria. Every specialty is going to have their own model for dealing with CKD/CKM (PCP, NKF's CKDintercept, American Heart Association will claim cardiology, etc.). We will get better (hopefully) at identifying where patients are best managed, whether PCP or specialty care, and that will inform the ROI on care navigation from policy, operations, and health system standpoints and help us deal with that old chesnut of heterogeneity in the CKD population, which is so endlessly maddening to the good folks paying for all of this.
2. As usual (and why does he really need any help?) the devil is in the details on the PIN codes. It is great to have them and incident-to billing is an operational challenge, to say the least, and that is subject to the same opportunity cost as we see with KDE of, "is this really worth my time?" That would be the argument for the ChenMed model of working with care navigation through a total cost of care model where optimally, navigation and faciliation become part of the care model. On the other hand, having a traditional fee-for-service model makes it much easier to try out PIN and see what works, especially with a mixed short-term ROI. So, as with most things, chicken or egg, etc.
3. I think there are many opportunities to improve care navigation with community health workers, particularly in settings where cultural concordance is very important (like dialysis). There, the reimbursement issues are more concrete but also more solvable. For example, the nephrologist billing the MCP can initiate services and then a CHW can step in and be paid. Similarly, an ESRD Network can hypothetically initiate services, but it would have to be under an NPI, etc.
I personally have not but would be interested to see who is using them in CKD. I think there is definitely an opportunity to utilize them in at least advanced CKD (stage 5) and those with CHF and CKD.
Tim, great article as always! The road to optimizing CKD care is a long one but we will get there. I am a firm believer in that the change has to come from the practice culture level to be impactful. Hopefully some of these novel codes will help drive that change.
Thanks, Jay! Appreciate you reading and I hope so, too. I know there are other billable services that have clinical and economic benefits but remain vastly underused (e.g. MNT, KDE). Have you seen / heard these PIN codes being used much yet?