Like all practices, medical specialty groups are facing severe challenges from declining Medicare payments, workforce shortages and escalating costs. But a major nephrology organization is tackling these concerns by collaborating with primary care physicians, providing extensive patient education and focusing on addressing problems as far upstream as possible before patients’ health conditions worsen.
Founded in 1971, Dallas Nephrology Associates (DNA) has been a leader in providing kidney care in the Dallas-Fort Worth metroplex, and its growth reflects the population boom seen in its home base. DNA now has more than 100 nephrologists practicing in 30 locations throughout the region.
Several DNA physicians serve as directors of nephrology and transplant departments at major Dallas and Fort Worth hospitals, including Baylor University Medical Center, Methodist Medical Center, Medical City Hospitals, Baylor All Saints Hospital, Texas Health Presbyterian Hospitals, and most Dallas-Fort Worth area hospitals.
Dallas Nephrology Associates is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Alexander Liang, MD, has been at DNA for almost half of the organization’s existence, including the last seven as its president. He has witnessed the explosive growth that has taken place.
“DNA is a unique practice in a sense that we've grown organically,” Dr Liang said. “DNA is the size that it is not by buying up a lot of groups—we've gotten bigger over time just as the DFW area has grown.”
But even as the organization expands, it remains true to the culture and principles it was founded on more than a half century ago.
“The glue that holds us all together is culture of quality and putting patient care first,” Dr. Liang explained.
“It's always been that way from the beginning and that's why I joined the group back 21 years ago,” he added. “I really, truly feel that that is what has helped us all stay together: Creating programs and even business endeavors with that priority—if it's not patient-focused, it's not worth doing.”
The need for nephrology services has never been greater.
An estimated 37 million adults in the U.S. have chronic kidney disease (CKD), and every day, another 360 people begin dialysis treatment for kidney failure—with much of it brought on by diabetes and hypertension, according to the Centers for Disease Control and Prevention (CDC).
It cost $87.2 billion to treat Medicare beneficiaries’ CKD in 2019 and an additional $37.3 billion to treat end stage renal disease (ESRD), the CDC says.
“Everybody understands the fact that health care is getting more and more expensive and there is just a limited number of dollars,” Dr. Liang said. “Everybody's also noticing that, if we intervene on these patients earlier and keep them healthier, they will not progress as much toward dialysis which in turn will decrease the cost to the system.”
This movement has been facilitated by value-based payment models that incentivize quality improvement and cost reduction for both specialists and the primary care physicians they collaborate with.
“The only way to do it is for us to be a good partner with primary care physicians,” Dr. Liang explained. “We can't all work in silos.”
He added, however, that for value-based care models such as accountable care organizations (ACOs), specialists are lagging behind their primary care colleagues.
“Primary care ACOs have been good at figuring out how to do value-based care and understanding cost,” Dr. Liang said. “We as nephrologists are much further behind primary care in this.”
DNA is participating in Kidney Care Choices (KCC), a practice model that was launched last year by the Centers for Medicare & Medicaid Services (CMS) and continues through the end of 2026.
“Patients with chronic kidney disease may experience fragmented care and high-cost treatments that do little to slow disease progression,” CMS says. “They also receive limited to no education about their disease and treatment options.”
The KCC model aims to correct these deficiencies by providing patients access to the physician of their choice and educational materials “to help empower them to be more active in their care.”
DNA has had a major focus on patient education for almost 10 years. Efforts have included producing their own educational videos and printed materials and training physicians to provide one-on-one counseling.
“We've realized years ago that the root of the problem is patients not really understanding the disease process,” Dr. Liang said, adding that DNA has hired six dietitians who also help with the education effort.
Another aspect of DNA education efforts is reaching to collaborating primary care physicians on how they can work better together and during which of the five stages of CKD should they refer their patients to a nephrologist.
“Traditionally, nephrologists have seen patients at stage 3,” Dr. Liang said. “But in many cases, I don't mind seeing patients at stage 2, because I'm just going to see those patients maybe once a year and make sure they understand the things that they should be doing in order to keep their kidneys healthy.”
The other issue is that often primary care physicians and practices are so busy, they don’t have time to fully explain to patients why they are being sent to a nephrologist and what can be expected from the visit.
“Patients don't really truly understand why they're coming,” he said. “Patients see a lot of doctors, so why do they need to come and see yet another one? That's part of the challenge and also another opportunity for nephrologists to collaborate more with primary care physicians.”
Dr. Liang uses a HIPAA-secure, web-based platform to solve some of these communication issues by providing team-based chats and clinical document exchange.
The big challenge is “trying to figure out how to keep people healthy by understanding that we have to spend dollars in certain ways to accomplish that so that we can all ultimately achieve savings by keeping them out of the hospital and preventing progression to dialysis,” Dr. Liang said.
Those are “important goals for us as nephrologists.”