Hello everyone, and thank you for tuning into the
Becker's Healthcare podcast series. I'm Marcus Robertson, reporter
for Becker's Healthcare, and today we'll be talking about how
value-based care for kidney disease is really starting to take off. I am lucky enough to be joined by two
incredible guests today in that regard. Bobby Saka, who is c e o of
InnerWell Health, and Dr. Steven Friedhoff, the senior Vice President of Healthcare
Service at Blue Cross North Carolina. Bobby as c e o brings over 10 years
of value-based kidney care experience to his role, uh, having served as c e o of Cricket Health
and as a senior executive and policy and corporate affairs at SIUs
Medical Care. Joining Bobby, as I mentioned before, is
Dr. Steven Friedhoff. Dr. Friedhoff has more than 20
years experience in clinical, academic and administrative
leadership roles. He most recently served as Chief
Clinical Officer for help at home. And prior to that, Dr. Friedhoff served from 2008
2020 at Anthem Blue Cross Blue Shield as Enterprise Chief Clinical
Officer, Bobby and Dr. Friedhoff. Thanks for being here. Thanks for having us. Thank you. Absolutely. Well, uh, you know, I mentioned up top that we are
talking about kidney disease. Um, I'm sure both of you know that
there are about 37 million Americans with kidney disease. What is the biggest
challenge in caring for all of them? Yeah, I'll start Marcus, think
again. Thanks for having us. Um, a as you mentioned, there's 37
million Americans with kidney disease, but f I think largely through
a policy quirk all of the time, attention and focus in this country has
been on this roughly 600,000 Americans who are, who are on dialysis. And
the reason for that is that in 1972, Medicare, um, conferred automatic eligibility on those
who were suffering from end stage renal disease. So all of the money flowed
into, uh, management of dialysis, which was a remarkable feat.
It saved millions of lives. Um, the challenge however, is
that it kind of ignored, um, the tens of millions of Americans who
have kidney disease prior to kidney failure. And so for decades, that's
been a largely unmanaged population. And to compound things,
it's uh, it's can be an un, un and underdiagnosed
disease cuz it's, uh, people don't really know when
they have it. So as a result, what's been happening in the last, uh, do several decades is that the standard
of care for far too many people is to do something called crashing into dialysis. They show up at the emergency room with
chest pain or blurred vision with no idea what's wrong with them. And the doctor runs a very simple blood
test and tells the patient that their kidneys have actually failed and they
plunk a catheter in their neck and tell the person that they're on dialysis that
day and for the rest of their lives. So that's the challenge
that we all face here, and that's the sys the systemic
challenge of, of kidney disease. What we are doing in partnership with
folks like Blue Cross Blue Shield North Carolina is to engage patients
earlier to identify patients who are in stage four, stage five, a year and a
half to two years prior to kidney, uh, failure, trying to engage 'em in their
care, help them understand the disease, manage their meds, manage their diet, all in the hopes of slowing
the progression of the disease. And if they do progress to kidney failure,
they're a much healthier person. Uh, they understand their options
and hopefully they can get
referred for transplant or even start to dialyze at home. Yeah, thanks Bobby. And, you
know, from the Blue Cross, North Carolina perspective, you
know, at the highest level, you know, we're committed to making healthcare
more affordable, more accessible, and certainly easier
to navigate. And yeah, obviously I look at that through the
lens of my role in North Carolina, but at the same time, I look at it
through the lens of a, you know, family physician as well. And at
at the highest level, you know, we have a program in North Carolina
called Blue Premier, you know, that is focused on
value-based care. And oh, since inception it's saved
about 500 million in total cost of care, 130 million of
that just alone in 2021. And two thirds of that actually goes
back to providers in terms of incentives to continue that virtuous cycle of
value-based programs. But, you know, the cost savings isn't enough. And as we look at some of the value
that we've derived and our members patients have derived from
Blue Premier, you know, across the board and not
specific to kidney care yet, but across the board we've
seen significant reductions
in things like hospital readmissions, increases
in the percentage of, of members who are better managing
blood pressure and diabetes, and improvements in things like
cancer care screening as well. So when we look across, you know, the spectrum of the types of conditions
that are most amenable to management, kidney disease rises to
the surface pretty quickly for a few different reasons. Um,
as Bobby mentioned, you know, 37 million Americans have kidney
disease and it is a complicated illness. It requires very active management
and frankly, that's not always done. Patients don't necessarily feel badly
until they have fairly advanced disease. And it takes a multidisciplinary
approach to manage this condition very, very well, including early
referral to, to a kidney specialist. Um, there are social barriers that certainly
affect management of this condition, you know, just like any other condition. But things like reliable transportation,
especially for those on dialysis, you know, trusting in their providers
trust in the healthcare system overall, you know, particularly when, again, people don't necessarily feel bad when
they have kidney disease until it's quite advanced. So this holistic approach
to care that Bobby described is, you know, it's a, it's important
across the board in healthcare, but it really has a disproportionate
impact on those with chronic kidney disease. Hence, you know, the reason that this is such a big
focus for both of our organizations. If I am a patient, I wouldn't, I
think want my experience to be, uh, characterized as crashing
into dialysis. You know, that does not sound fun. No. You. Know, you've gone wrong when,
uh, the medical term is. To crash. You're exactly right. Yeah,
absolutely. Absolutely. Um, well, uh, I wa wanted to clarify something real
quick. Uh, Dr. Friedhoff, you said, uh, the blue premiere program, uh, did you say two thirds of the cost
savings for that go back to providers? Correct. So we provide incentives, uh, for providers based on
reductions in total cost of care as well as improvements in the
quality of, of care delivered. So when I mentioned earlier things like
reduced hospital, um, readmissions, better management of chronic conditions
like blood pressure and diabetes, you know, cancer screenings,
things like that, um, we have quality gates that, um, you know, provide for enhanced payments
to providers for, um, improving quality as well as for reducing
total cost. And the reality is that, you know, providers to provide this
kind of management to their patients, you know, it's, it it takes additional resources
and to provide and to, um, uh, reward the investment in, you
know, individuals and technology, et cetera, that allow providers to do a better
job of managing their patients. Um, it's, it's very important for,
um, them to realize, you know, some of the savings that result from
this program as reduc as a result of the reduction in total cost of care, as
well as the improvements in in quality. Realistically, it's only
sustainable if it benefits patients, if it benefits providers as well. Yeah, those incentives
have to be there. Um, but you actually mentioned another thing
I'd like to, uh, circle back to, um, something actually that I've heard from
quite a few leaders in kidney care, and that's the common refl
refrain that, uh, you know, chronic kidney disease
is just wildly complex, especially once you're dealing with
those later stages. Um, but why, why exactly is treating people
with chronic kidney disease? Uh, so tricky. Again, I I I look at this through
the lens of both, you know, blue Cross North Carolina as,
as well as a family physician, and there's always that
intersection. So a again, it is a complex illness, and I don't want to make this
an overly clinical conversation, but if you think about it, TVs normally maintain an individual's
fluid balance as well as the balance of electrolytes and many, many other
things. Some of them are, you know, like sodium and potassium are very
familiar to us, but many others, there are many others that most people
have never, ever, ever heard of. And these all have to be managed kidneys
are also involved in the metabolism of many important medications such that
changes to the drug doses are necessary as someone's kidney status deteriorates
and failure to do so can be catastrophic. And one of the most important
aspects of kidney care is also controlling and managing
diabetes and hypertension. By better managing those conditions, you can actually significantly
slow the progression of, uh, deterioration of kidney
function over time. So it's really this intensive
intersection of close patient monitoring, um, managing of diet, managing of medication and planning not. So it's not just what's
happening today with the patient, but also planning for
what's going to happen, anticipating potential complications
rather than dealing with them when they occur. And that really takes
a very specialized approach. Steve's exactly right, and you think about all those
complexities that hypertension, diabetes are such significant
drivers of kidney disease. Um, you think of all of the, the meds that
the, a lot of these patients are on, on average dialysis patients
have eight or nine, you know, medications that they're, that they're
dealing with. And as Steve mentioned, uh, drugs that are perfectly safe, um, with
someone without kidney disease become, you know, potentially fatal for those
who progress, uh, through kidney disease. Now, think about what all that does
to the patient. They're navigating, you know, they're very sick, they're very ill and they've gotta
navigate their P c p, their nephrologist, multiple specialists. So we all talk about the siloization
of American healthcare. Um, it is exacerbated in the extreme for poor
kidney patients having to bounce from specialist to specialist. So unless and until you have that
holistic approach that Steve talked about, where you can bring all of
those specialists together, where you can have all of the, the various care teams involved with
this patient's care speaking, uh, from the same, you know, singing
from the same sheet of music, less than until you can do that, uh, patients are going to be bouncing
around from one to the other, not sure who's who to believe. So
it's incredibly complex clinically, and as a result, it becomes a huge burden just to try
and navigate the healthcare system for patients themselves. So kidney disease can turn
otherwise benign, medicines fatal. Absolutely. And it sounds like, uh, you know, this touches on so many different
specialties in different ways, um, so, you know, involving, uh, uh, including a full care team and
that makes sense to me, but, um, how are some of these, uh, you know, new models of value-based
kidney care able to both improve the outlook for patients
and manage to do so? Um, you know, with lower overall costs
than traditional care models? Well, something that Steve mentioned I
think is critical and what Blue Cross North Carolina is doing with
Blue Premier is fantastic, and that is you have to make sure
that clinicians have more clinical and financial accountability for patients.
But you also have to make sure, as you said earlier, that
the incentives are aligned. And by working in partnership
with providers like
InnerWell and our network of nephrologists across the state,
we're able to partner with, with Blue Premier set benchmark spending
amounts to make sure that we try and, uh, stay underneath them while also hitting
those quality metrics or quality gates that Steve talked about to make sure
that we're improving patient care. If you can do that, um, then
you can really drive some
significant improvements. Uh, in essence, what Blue Premier has figured out and
what a lot of payers across the country have figured out is it makes a lot of
sense to spend money today in the hopes of saving even more money
tomorrow. And that in, you know, in in its essence is value-based care.
What we're able to do then with that, with those resources, you know,
prior to this, we, we were just, no one was ever paid for chronic kidney
disease engaging patients prior to kidney failure. Now there's an
economic incentive to do so, and it's helped us organize the network
to be able to give the physicians in North Carolina the data resources they
need to embed staff to support them with a, with a multidisciplinary care team, with pharmacists to help out with the
contraindicated drugs that you mentioned earlier, social workers, dieticians.
Um, that's the, I think the, the key piece surrounding
the patient with all of the, the care team that they need to
be able to navigate this disease. And then significantly, and, you know, getting to the point we were talking
about earlier, making sure that the, that the nephrologists, the kidney doctors and our care teams
as well as the dialysis clinic staff are all on the same page and all working
together with the, with the patient. If you don't bring all of those assets
together and have 'em all communicate, then you're just reinforcing
the siloization of healthcare
and you're not moving the ball forward. Yeah, Bobby, you said it
very, very well. And again, it gets back to focusing on a
patient-centric, very holistic approach, and also rewarding providers and
allowing them to make that investment, you know, in their practice and other
capabilities in the case managers, in the pharmacists, in the
social workers, et cetera, that ultimately improve outcomes, lower
medical costs. Um, along with that, and case managers are a
wonderful support with individuals with complex and chronic
conditions. And as I mentioned earlier, kidney care is so highly specialized.
It requires not just the case managers, but other types of providers, um, that surrounds the patient and
are adjuncts to the nephrologist, the kidney specialist, but who also have extensive experience
not only dealing with the complications that are occurring today,
but as I mentioned earlier, knowing the usual course of the condition, knowing how and when to intervene at
the right time and how best to prepare patients not only for
what's happening today, but to do so on a much more proactive, ac proactive basis so that
complications can be avoided. Making sure those incentives are
aligned is is part of, you know, uh, keeping the lower cost and
driving those improved outcomes. And there's a bit of an upfront
investment it sounds like, but that will pay off in a
potentially massive way down the road, especially with something like
chronic kidney disease. Um, so all of these stakeholders being
aligned, what why is, uh, you know, partnering with physicians
specifically, uh, really key to the success here
when you're managing, uh, you know, c k D patients who are an especially
vulnerable population, it seems like. I think for me, there's, there's,
there's a more obvious answer and a, and a less obvious answer. I think the obvious answer for why we
partner with physicians is that while the patient is at the center
of this holistic care, the physician generally leads or at
least sets the stage for the overall care team. And it's the physicians
who in through their practices, make those investments that are required
to reach out to individuals with chronic kidney disease,
educate them on their disease, ensure that the is managed
effectively and appropriately. And even though their non-physician
staff will do a lot of that work, the physician practice has to make those
investments and set the expectations for the outcomes. But there's
some less obvious things as well, and I think we both alluded
to them earlier, for example, controlling blood pressure and diabetes
is absolutely critical to slowing disease progression. Even that portion of the education and
the monitoring that goes with it can be very, very time consuming, yet it's one of the most important
things that can be done to prevent kidney disease progression. We also know that early engagement with
a kidney specialist is, is critical, and ideally we want to start
that much sooner than this, um, but a well-recognized quality measure is
ensuring that patients see a specialist at least six months prior
to starting dialysis. Uh, the reason for this is that there's
so much preparation required, um, either for, uh, you know, potential, uh, onset of dialysis or even
a potential identified, uh, potential transplant candidates. And
as Bobby alluded to earlier, you know, too many patients can crash
into dialysis, you know, meaning they're only identified as a
late stage and during the later stage of their kidney disease, during a medical
crisis, usually a hospital admission. And this is a much more risky situation
for the patient. It's far more costly, um, and it's certainly not the
optimal way to begin dialysis, and it's completely avoidable, and it starts by seeing a physician
specialized in kidney care much sooner and much further upstream
in the course of the disease. Y Yeah, I couldn't agree more. I mean,
physicians want to help patients. That's, that's, they're calling,
they're the experts, and we know that when physicians
see a nephrologist, they do better. Those are just the facts. Any model
or any idea that you can do this, you can engage patients
and, and really truly, uh, try and improve their outcomes
without engaging the physician. To me and to Dana, well completely
misses, misses the mark. Um, and as we talked about too often a patient
who's suffering from kidney disease, they're not even seeing a kidney doctor, they haven't seen a nephrologist
when we be begin managing their care. So for us, it's all about making sure
that we can refer them to our physicians, which is why we're so proud to partner
with groups like Eastern Nephrology and Metrolina in North Carolina, some of the biggest and best practices
in the state. Um, but, you know, working in partnership
with them is, I think, critical because I think they'll be the
first ones to tell you that there's a whole host of follow up that they
know they need to do and should do, but don't too often don't have the
time or resources to be able to do it. And that's where someone like
InnerWell can come in where again, we can give them the data, we can embed resources like care managers
in their practice and then support them with our virtual care
teams, nurses, dieticians, social workers only by working
together in this, you know, creating this sort of new
comprehensive ecosystem, can you start to drive the kind of results
that we're starting to see, you know, reducing all cause hospitalizations
across our population by 15% in the pre-dialysis population, and 19%
in the dialysis population, uh, doubling the number of people
on a percentage basis who
are starting dialysis at home. Uh, the national average is around
12, and we're, uh, just shy of 25%. So again, it's, I think there's no
mystery in terms of what has to get done, and I think Steve has been very
eloquent in describing the, the clinical challenge
facing this population. It's about aggressively going upstream
and identifying these patients and then providing them the care and support. But
if you do that without the physicians, and Marcus, to the point you said earlier, then now you've got completely
mismatched incentive. There's no alignment either financially, but more importantly clinically and from
a workflow perspective, and then again, the patient's left, uh, trying to
fend through the system on their own. Yeah, that's, I was going to
touch on that. You know, c k d, like we said earlier, incredibly complex, but so is the healthcare system to
patients a lot of the time. So, um, yeah, you, you said it sounds
like a, uh, you know, maybe not a side effect maybe is intended,
but, uh, partnering with physicians, like you're saying, really sounds like it can help patients
in a big way navigate their own care. But, uh, to close this out at Becker's, we're always trying to keep an eye out
on, you know, for what's on the horizon. Obviously we're a news
agency, Bobby, Dr. Friol, what do you think kidney care
looks like going forward? I think one of the things I'm
particularly excited about is, um, just, just the renewed focus
on the disease, the, the recognition that we
have not done enough for, as we talked about at the outset, that tens of millions of Americans
are suffering from the disease, but often don't even know that they
have it. Plans like Blue Cross, North Carolina have now
understood, um, with, you know, with better data and just better
overall care management services, what can be done by engaging
patients earlier. Now, the next, uh, I think that sort of the next foray and
the next frontier of this is better and tighter integration we've talked
about with, with physicians, uh, with nephrologists and with dialysis
clinics and with our own care managers now it's engaging the primary care doc
going even further upstream, uh, earlier stages. So you can work with the primary care
docs to have that really seamless transition and handoff between
the primary care doc and the, and the kidney physician, um, but also working in concert with the PRI
primary care doc to really do a better job of all the things that Steve
talked about, managing hypertension, managing diabetes, so that we can really get our arms around
slowing progression once and for all. Um, I think that's the very exciting
piece of this. And on the flip side, of course, is for those patients
who have progressed all the way to, to endstage dialysis or endstage
kidney disease or, and our, and are on dialysis partnering with, with primary care docs to bring
them into the dialysis setting, um, so that now patients again don't have
to go from their dialysis clinic, which is a grueling
treatment three days a week, and then have to see their primary care
doc as well, um, creating this, again, holistic SY system system that's focused
around the patient. I think that's the, the next iteration of this, and
I'm, it's something I'm very, very excited about. Yeah, Bobby, I completely
agree. And, uh, yeah, it, it could almost sound like we, we rehearsed this ahead of time and
we didn't because, uh, you know, my, my thoughts are very,
very similar. You know, I think with any chronic condition, um,
kidney disease or other, there's this, you know, risks sometimes that when we think
about future improvements in treatment, it's a, it's, you know, the first
thought goes to what new technology, what new drug, you know, what what,
um, you know, high tech, new therapy, and I think kidney care like many
other chronic conditions really get, gets back to the fundamentals,
right? So for example, how do we take care for
somebody who's say on dialysis out of a facility and out of a place
where they need to be out of the home and getting awry frequently, and,
you know, things like that. How do we increase the focus on home
dialysis for the right patients, both peritoneal and, and hemodialysis
for those who have reached that, that stage of kidney disease, again, with much more of a focus on the
home and much more of a focus on, on the patient rather than
the healthcare system per se, taking chronic condition
identification and management further upstream, you know, right now, uh, intra and Blue Cross North Carolina
are focused primarily on c k D stages for N five and, and those,
uh, on dialysis. Um, we both are exploring ways of how do
we take this further upstream and start doing a better job of managing, uh,
chronic kidney disease, you know, at this, at stage three for example, and taking
things even further upstream in that, how do we continue to engage PCPs,
whether it's through Blue Premier, um, or other programs so that patients
are more readily identified far earlier in their diagnosis.
They receive better care very, very early, um, in their, uh,
progression of chronic kidney disease. First starting with the P C P, making sure they have the benefit of
an early referral to a specialist. And then as Bobby pointed
out, ensuring that Winston, they're engaged with the specialist
that the P C P and potentially other concerns and conditions that
the patient has are, you know, not lost in just the swirl of everything
else going on related to their, their kidney disease. So it really gets back to the
basics of holistic care and taking prevention further upstream. Well, a hopeful outlook to end
on for sure. Thank you gentlemen, both for your time and a really, really
great discussion today. I enjoyed it. Okay. Thank you, Marcus. Thank you, Bobby. Thank you. It's great to be here. Like to also thank Inter Health for
sponsoring this episode for our audience. You can tune into more podcasts
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