Early Chronic Kidney Disease (CKD) Identification: Why it Makes Strategic and Financial Sense for Health Systems

Every year at Kidney Week, much of the conversation naturally centers on the exciting clinical breakthroughs transforming nephrology. Yet inside the C-suite of health systems across the country, a different conversation is taking place: how do we manage a sizable, largely undiagnosed chronic disease population when our clinical teams are already stretched to their limits? The answer starts with early CKD identification.

Chronic kidney disease (CKD) affects roughly one in seven U.S. adults – approximately 35.5 million people. Yet up to 90% of those with reduced kidney function are completely unaware they have it; and 40% with severe (stages 4-5) disease do not know their kidneys are failing, according to the CDC. In fact, many of these patients are identified first in the emergency department in acute renal failure requiring urgent catheter placement and costly inpatient dialysis initiation.

For health system executives, shifting the paradigm from late-stage crisis management to early CKD identification – particularly among high-risk patients with diabetes, hypertension and other distinct underlying etiologies – is more than a clinical quality goal. It is a powerful strategic lever that drives meaningful financial performance, relieves downstream operational bottlenecks, and improves patient outcomes without overburdening an already exhausted workforce.

 

The Clinical Case: How Early CKD Identification Changes the Trajectory of Cardiorenal Risk

Early CKD identification matters now because clinicians finally have therapies that can delay the progression of the disease. For decades, a diagnosis of early-stage CKD felt largely observational; clinicians had limited tools beyond basic blood pressure and glycemic control to slow down the decline. And for distinct underlying etiologies there were no available treatments. Today, that clinical reality has fundamentally changed.

Early CKD identification allows care teams to intervene when disease-modifying therapies are most effective. The introduction of new therapies for metabolic CKD and of newer therapies for genetic and immune-mediated etiologies or rare kidney diseases has given clinicians the ability to significantly delay disease progression.

Crucially, the benefits extend far beyond the kidneys. Most patients with CKD face a much higher risk of a catastrophic cardiovascular event – such as heart failure hospitalization, myocardial infarction, or stroke – than progression to end-stage renal disease (ESRD). By identifying declining renal function early via programmatic screening in patients with diabetes and hypertension, health systems can initiate guideline-directed medical therapy that simultaneously protects the kidneys and bends the curve on costly cardiovascular admissions.

 

The Financial Case: Four Levers of Value From Early CKD Identification

In an era of tight operating margins, clinical initiatives must demonstrate a clear return on investment. Proactive CKD identification and management unlock four distinct financial drivers across both fee-for-service and value-based care models:

1. Accurate Capture of High-Value HCC Codes (Stages 3–5 CKD)

Under risk-adjusted reimbursement models – including Medicare Advantage and Accountable Care Organizations (ACOs) – accurate Hierarchical Condition Category (HCC) coding is essential to ensure health systems receive appropriate resources to care for medically complex populations. While labs and other diagnostics may indicate advancing kidney function impairment, Stages 3, 4, and 5 CKD frequently go undocumented on the problem list and unbilled during clinical encounters. Systematic identification and documentation of Stage 3–5 CKD directly improves Risk Adjustment Factor (RAF) accuracy, ensuring capitated benchmarks and shared-savings targets reflect the true acuity of the patient panel.

2. 340B Pharmacy Margin on Guideline-Directed Therapies

When providers identify CKD early in patients with diabetes, hypertension, or heart failure, clinical guidelines strongly support the initiation of SGLT2 inhibitors (SGLT2i). For health systems participating in the 340B Drug Pricing Program with robust specialty and retail pharmacy capture strategies, appropriate utilization of SGLT2i therapies creates a substantial pharmacy margin opportunity. It represents a rare alignment in healthcare where closing a critical clinical care gap directly generates margin to support the broader mission of the health system.

3. Planned Transitions to Renal Replacement Therapy (RRT)

Few clinical events are as disruptive to a patient – or as financially detrimental to a health system – as an unplanned “crash” into dialysis. Urgent inpatient dialysis initiation drives prolonged hospital lengths of stay, high readmission rates, and elevated mortality. Conversely, identifying late Stage 3 and Stage 4 patients early gives nephrology teams the runway needed to educate patients, evaluate them for preemptive transplantation, or surgically place the appropriate dialysis access on an outpatient basis. Planned starts preserve inpatient bed capacity, drastically reduce avoidable acute-care expenditures and save the patient from a traumatic and dangerous emergency event.

4. Capture of Home Care Services and Home-Based Dialysis

When patients crash into dialysis in the hospital, they almost universally default to in-center hemodialysis, often leaking out of the health system’s care network to commercial dialysis chains. Early CKD identification and proactive longitudinal management allow health systems to guide eligible late-stage patients toward home-based modalities. Not only do home modalities offer better patient quality of life and lower total cost of care, but they also enable health systems to retain patients within their ecosystem, capturing downstream revenue for home health services, training, and ongoing outpatient care management.

 

Taming the Numbers: How Smart Population Stratification Prevents Alert Fatigue

The most common hesitation from clinical leaders when discussing expanding CKD screening is simple and valid: “Our primary care providers are already drowning. We cannot ask them to manage thousands of newly flagged patients.”

The CKD population is indeed large, but the numbers do not have to be overwhelming. The challenge of traditional population health initiatives lies in treating all patients the same and enacting broad, sweeping population level screening.

Instead, health systems can apply clinical AI to identify the patients most likely to benefit from earlier intervention. By analyzing existing longitudinal lab trends, comorbidities, family history and demographic data already sitting in the EHR, health systems can segment their diabetes, hypertension and CKD populations into actionable tiers:

• Focused Screening: Identifying the specific subset of high-risk patients who are missing confirmatory testing, automating lab orders through standing protocols rather than manual physician clicks, and increasing pre-visit communication to help drive lab completion compliance.
• Primary Care Optimization: Flagging early-stage patients whose trajectory is stable enough to remain in primary care, supported by automated calculation of well-validated stage progression tools like the Kidney Failure Risk Equation and automated prompts for initiation of SGLT2i therapy.
• High-Priority Nephrology Referral: Pinpointing the narrow cohort of rapidly progressing, atypical or late-stage patients who urgently need a specialist referral, ensuring scarce nephrology appointment slots are reserved for the patients who need them most. With up to a third of nephrology fellowship slots going unfilled each year, those appointments will only get scarcer.

 

Who Owns CKD Care? Managing Kidney Disease Is a Team Sport

Ultimately, solving the CKD challenge does not fall on the shoulders of any single department. Sustainable kidney care is a team sport that requires coordinated workflows across the entire health system enterprise:

• Primary Care serves as the front line of defense, normalizing routine kidney health screening alongside standard metabolic panels for diabetic and hypertensive patients and initiating foundational therapies.
• Clinical Pharmacy plays a pivotal role in medication titration, managing drug-drug interactions, navigating prior authorizations, and helping patients access affordable SGLT2i and cardiorenal therapies.
• Nephrology focuses scarce specialized expertise on atypical presentation, complex diagnostics, rapid progressors, and late-stage care planning rather than stable Stage 3 monitoring.
• Home Care and Care Navigation Teams bridge the gap for advanced disease, providing the education, social support, and clinical infrastructure required to make home-based dialysis and smooth transitions of care a reality.

As we reflect on the advancements highlighted during Kidney Week, the takeaway for health system executives is clear. We already have the diagnostic tools and the therapeutic breakthroughs required to change the trajectory of kidney disease. By pairing smart population stratification with a coordinated, system-wide care model, health systems can protect their clinicians from burnout, strengthen their financial foundation, and deliver life-changing proactive care to the patients who need it most.

 

Key Business & Strategic Questions in Health System Kidney Care

Why should health systems have a programmatic approach to guideline-directed kidney care in primary care?

The coming demographic tsunami of an aging population, increasing incidence of diabetes and comorbid CKD will overwhelm already strained nephrology capacity unless primary care can act to slow disease progression. According to the American Society of Nephrology, up to a third of nephrology fellowship slots go unfilled each year and with the average age of nephrologists at 55, the problem is only getting worse. SGLT2i therapies have shown great promise in slowing disease progression and reducing cardiovascular events, but they only work if they’re used. Primary care needs programmatic support to encourage better prescribing for qualifying patients in order to prevent costly unplanned admissions, reduce the volume of patients needing specialty care, and to enable 340B systems to access pharmacy margin.

How does CKD staging affect risk adjustment?

Unspecified or incorrectly documented CKD is lost revenue. CMS-HCC V28, now fully phased in for 2026, changed how kidney disease is valued:

• CKD weights went up. Stage 3a and 3b now fall into separate Hierarchical Condition Category (HCC) groups, and the risk adjustment factor (RAF) value increased for all CKD groups. Importantly, CKD etiology needs to be coded and stage must be independently specified. Stage 1, stage 2, and unspecified CKD (N18.9) no longer map to a payment HCC.
• Diabetes complications no longer carry their own weight. V28 constrained the diabetes HCCs so every coefficient is the same regardless of complication status. While the coding for diabetes with kidney complications is still important for establishing kidney disease, the risk adjustment value for kidney involvement in a patient with diabetes now shows up through the staged CKD diagnosis, not the diabetes code.

Lab results alone won’t produce the documentation: the correct diagnosis with appropriate staging has to be documented in a patient encounter each year, or Medicare Advantage and Accountable Care Organization (ACO) benchmarks will understate the true disease burden of your population.

Which quality measures reward kidney health screening in diabetes?

The HEDIS KED (Kidney Health Evaluation for Patients with Diabetes) measure and MIPS Measure #488 both require two tests in the same year, an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR). While compliance with the eGFR is generally high, most systems miss the uACR, and that gap drags down quality scores tied to MIPS payment adjustments and value-based contract performance. Patients who are contacted in pre-visit planning or encouraged to complete their labs prior to their scheduled disease management visit are more compliant with completing the full set of disease management labs. Primary care needs programmatic support with patient engagement to drive improvements.