#989 Fund and incentivize multidisciplinary CKD care: what can we learn from the French CKD bundled payment program?

Abstract

Abstract Background and Aims Multidisciplinary care (MDC) is crucial to slow down the progression of Chronic Kidney Disease (CKD) and prevent or post-pone kidney replacement therapy. To incentivize the development of that care, France launched a nationwide bundled payment program (CKD-BP) targeted to patients with CKD G4 and G5. In this study, we review the implementation of the program, 3 years into its launch. Method First, using the CKD-BP program data collected by participating facilities, we described the characteristics and trajectories of patients enrolled from 2020 through 2022. Second, from exploratory interviews with medical and management staff, we performed a thematic analysis to identify the obstacles encountered during implementation and the changes introduced by the program. Results Since 2020, 157,863 patients were reported by 408 facilities (median age 75 y-o, 40% women, 77% G4). Missing data frequencies were high for comorbidities. Each year, around 4200 dialysis start (5% of patients) and 2600 deaths (3% of patients) were reported. On average, 47% and 40% of patients visited nurses and dietitians at least once a year respectively. From 22 interviews across 7 facilities, we identified challenges of implementation: adapting information systems, gathering the support of facility management and organizing the care in a context of workforce shortage, specifically nurses. Despite those challenges, facilities welcomed positively the new model, notably with increased time between nurses and patients and affirmation of dietitian's role. Conclusion We estimate the exhaustiveness of the CKD-BP program at 40% of all French patients with G5 CKD (around 4,600 dialysis start reported in 2021, compared to 11,000 from the national exhaustive REIN registry data). The results of this study suggest that interventions to accompany facilities in adapting their information systems are a priority to ensure efficient allocation of medical time and quality of the data. The results also suggest the need for increased flexibility regarding what professional is considered in the CKD-BP program, beyond nurses and dietitians. These challenges remain to be addressed in order to complete a successful shift from fee-for-service to assessable value-based care for CKD in France.