Podcast - Closing the Gaps in Kidney Care Access

How do we build a safety net for millions of Americans living with chronic kidney disease (CKD) who don’t have the care and support they need to manage this complex, degenerative condition? Unfortunately, a large portion of patients with CKD either lack access to a nephrologist or remain unaware of their condition, leading to more severe health complications over time. In this episode of Kidney Health Connections, Dr. Julie Dominguez, Interwell Health medical director, dives into the critical role of nephrologists in improving patient outcomes and explores innovative solutions to bridge the care gap in settings where patients don’t have a nephrologist.

To create a comprehensive kidney care safety net—especially in the face of an ongoing nephrologist shortage—Dr. Dominguez shares how Interwell Health works to connect patients with local providers and, when needed, leverages advanced practice providers (APPs) and telehealth to provide focused interim care. She also discusses the role of technology, including predictive analytics and electronic health records, in identifying patients in need of additional support and creating seamless care transitions.

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift of value-based care, where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: Hello everyone. We know people living today with chronic kidney disease have better outcomes and improved quality of life when they're under the care of a nephrologist. But unfortunately, many CKD patients don't have a nephrologist. Even more concerning, there's a significant population of patients with CKD who are totally unaware they have kidney disease.

How can we bridge the gap to ensure more patients with CKD receive appropriate care before their disease has progressed or before they crash into dialysis? And how can we ensure that patients have the support they need in time sensitive situations such as after a hospitalization? These are questions our guest today, Dr. Julie Dominguez, has been wrestling with now for several years, along with the entire clinical team at Interwell Health.

Julie, excited to have you here today and look forward to our conversation.

Dr. Julie Dominguez: Thanks for having me.

Dr. George Hart: You've been a practitioner now in a lot of different settings. You've been on the west coast, middle of the country, academia, private practice. You have seen the impact of the challenges of access to care and the care gaps that it provides or creates for patients. How does this lack of access lead to care gaps?

Dr. Julie Dominguez: Unfortunately, when patients don't have good access to care, it means that they're not always aware of the diseases that they have, and CKD is no exception to that. So, when you take somebody who's not aware of having chronic kidney disease, then you're delaying their time to get to a nephrologist. You're delaying the time that it takes to get them on the right drugs like even ACE or ARBs, but SGLT2 inhibitors and GLP1s that can help slow progression.

And then ultimately what you end up with is a more advanced CKD patient who hasn't had the opportunity to have education, kidney specific care for their CKD. And that patient is at much higher risk for a crash into dialysis, for hospitalizations, and just for adverse outcomes that worsen their quality of life and lead to worse outcomes like less optimal starts.

Dr. George Hart: And for this audience, an optimal start means you transitioned from CKD to either getting a kidney transplant preemptively or you started dialysis without one of these pesky indwelling permanent catheters, right?

Okay, so I appreciate what you've just illustrated for everybody, but I think for our audience it might be useful if you can actually paint a picture for what this looks like with an individual patient journey.

Dr. Julie Dominguez: Sure. So, you know, let's say we have a 67-year-old man and he's got a GFR of 22, which translates into CKD stage 4, which is pretty severely progressed chronic kidney disease. He's got diabetes, which is probably the cause of his CKD because he's got about a gram of proteinuria, and we know that that protein spillage can occur in patients with diabetes—and it not only is a hallmark of kidney damage, but it also results in ongoing worsening of that damage. Like I said, he's got a GFR of 22 and he doesn't even know that he has chronic kidney disease.

At this point, this is a patient who, if I were seeing them in clinic or in the hospital, I would be talking to them about their chronic kidney disease. I would be talking to them about treatment options like preemptive transplant or at least a referral to a transplant center to start that process early. I would be talking to him about the likelihood of his progression of his chronic kidney disease to end-stage kidney disease, letting him know what that looks and feels like, what his treatment options are for if and when that does happen, and then doing everything that we can to try to slow that progression now to delay his time to dialysis and try to improve his quality of life.

And along with that, I would be doing things like trying to educate him about his disease, how to self-manage his symptoms and his other comorbidities like his diabetes, his hypertension. And I would be trying to do everything that I could, really, to help him live the best life that he can right now.

Dr. George Hart: And the problem with all of this is certainly a problem for this individual, but for a company like Interwell or a private payer in a Medicare Advantage program, this isn't a unique scenario. Sometimes 40 to 50 percent of the patient population that we are taking care of don't know. So this is a huge problem, right?

Dr. Julie Dominguez: It is. We know from our private payer patients that about 40 percent of them don't have a nephrologist. And that means that we're hoping that primary care providers are doing the things that need to happen. But many of them are already overworked, they've got many other patients to see, and they may not be the best person to really be giving kidney-specific education, or dialysis, or end-stage kidney modality education to patients. That's really, that's why we have nephrologists. That's what we're here to help do.

Dr. George Hart: And you mentioned early on—and I think this is an important point, because we've talked a little bit about transitioning into dialysis—but really the goal is let's figure out ways to slow the progression of kidney disease. And it's not just kidney disease that gets unrecognized and perhaps poorly identified and treated in this population. Right?

Dr. Julie Dominguez: That's right. I mean, the vast majority of chronic kidney disease in the United States is due to hypertension and diabetes, either solo or in combination. These are not diseases that, you know, cause kidney disease out of the blue. Kidney disease is a known complication of having long standing diabetes and hypertension. Again, treating those, seeing these patients, screening them for chronic kidney disease, trying to identify it early so that you can slow progression early, which is the ideal time to do it, that's really what we should all be trying to do for these patients.

Dr. George Hart: So the conversations that we've had, and we've had many of these so far, is that many times there is no local option and that we are struggling to connect patients to an appropriate physician to provide the kind of care you're talking about. What are some of the options that we're coming up with at Interwell to try and solve this gap and what are we thinking about in terms of how to bridge this care?

Dr. Julie Dominguez: We've had a long-standing program to try to connect patients to local nephrologists, which you've alluded to already. We try very hard to get patients into local providers who can see them where they live and help them understand, you know, what their options are and how to self-manage and slow progression.

As you alluded to, we're reaching a point where we're having trouble doing this with some subset of patients. And so in response, what we are standing up now is the Interwell Medical Group, which will utilize advanced practice providers and telehealth to help see these patients for focused urgent care in settings where patients don't have a nephrologist. They need some chronic kidney disease education.

They need better management of, say, hypertension, diabetes, some maintenance care for their chronic kidney disease.

And what we're going to try to do is get these patients seen a couple of times in this telehealth practice and then really try hard to continue to connect them to local providers.

Dr. George Hart: Because we talk about this as a local problem, and in many ways it is, but it's actually a national concern. So this medical group you're referencing will potentially be in multiple states, in multiple markets. And I would think that we need help in trying to discern how do we prioritize certain patients who need care sooner than others. Am I thinking about it in the right way?

Dr. Julie Dominguez: No, for sure. You know, I talked about no nephrologist patients, but as we've already said, that's about 40 percent of our payer patient population. We've already got an excellent data science team here at Interwell who's come up with some predictive models using machine learning to think about things like risk of progression, hospitalization risk, even readmission risk. One of the other populations of patients that we're talking about seeing in this medical group are patients who've recently been admitted to the hospital, don't have a nephrologist that they can follow up with after discharge and, if needed, we can step in and help see those patients. And again, that's where that readmission risk model can come into play.

So part of what we're going to do is really look at this population at a populational level and say, “Who really needs to be seen based on risk levels or concerning clinical markers?” and then bring those patients into the medical group.

Dr. George Hart: And those machine learning models that you are referencing have been quite helpful in predicting both hospitalization risk and risk of progression.

Dr. Julie Dominguez: Yes, absolutely. I think they perform very well in the payer patients that we have and actually even in our CKCC patients.

Dr. George Hart: It may also be helpful for our audience today to explain a little bit more in detail what the capabilities and opportunities we have with advanced practitioners in this setting.

Dr. Julie Dominguez: Advanced practice providers—and we have nurse practitioners who work with us—they really, at the top of their license, can practice almost exactly as a physician. And really what we're looking at doing with these APPs is having them provide E/M visits, at least to start, where the focus, as I said, was on basic CKD care, education, are you on the right medications to help slow progression when applicable? And then also managing comorbidities like hypertension, diabetes, and even to some extent heart failure by managing volume when needed in these advanced CKD patients.

Dr. George Hart: So they can order labs?

Dr. Julie Dominguez: They can order labs.

Dr. George Hart: Order medications, follow up on the consequences of any of these medications.

Dr. Julie Dominguez: Exactly.

Dr. George Hart: And do all that telephonically or through a telehealth platform.

Dr. Julie Dominguez: That's right, yeah. And we'll be using Acumen Epic, which will include the ability to potentially send messages back and forth to patients and help troubleshoot some of this as it comes up as well. But yes, primarily through telephonic and telemedicine means.

Dr. George Hart: And then we can then leverage health information exchange opportunities through Acumen Epic when we do find a local provider.

Dr. Julie Dominguez: That's right. And for our local providers who utilize Acumen Epic, our notes will be right there to see on these patients. The handoff becomes much more seamless when we've got local providers who are on Acumen Epic as well, because the notes will be right there.

Dr. George Hart: But the goal is not to establish sort of a permanent relationship.

Dr. Julie Dominguez: Our intent with this the entire time continues to be to connect patients to local providers. We do not view ourselves as a long-term solution because all of this is done via telemedicine. And I think that there really is value in having a local provider who can see you face-to-face in the clinic and talk to you about things like, you know, treatment options and CKD education.

Dr. George Hart: The whole reason that we're trying to solve this problem is we have this huge population of patients who don't have a nephrologist. We know that seeing a nephrologist can lead to better outcomes. But what we haven't really talked about yet is a little bit of how we got into the challenge of a shortage in nephrologists. You've been part of a training program in part of your prior career. Maybe you can educate this audience on how did we get into this situation that we find ourselves today?

Dr. Julie Dominguez: Yeah, I am, as you said, I worked at UC San Diego on faculty for a while, so helped train fellows. But at a later point in my career I actually was an associate program director with an internal medicine residency program. And so I feel like I've really seen this kind of from both ends.

I think nephrology suffers from a PR problem. It's not viewed as sort of one of the really exciting subspecialties in medicine, like cardiology or GI, where you get to do procedures. There's a real, I think, instant gratification that you can get sometimes from doing things like that for patients.

Nephrology very much is a long-term relationship building with patients and really, you know, getting to know them well and seeing them over the long term. And that may not feel very exciting to some people.

I think nephrology also gets a bit of a bad rap because a lot of nephrologists that trainees are seeing out in the community are seeing patients in clinic, they're seeing patients in the hospital, and they're driving around to dialysis units across the community. And that is probably—what I at least heard from trainees—is that's not really how they want to spend their time. That's a hard problem to solve because all of those patients in all of those locations need to be seen. And especially with a dwindling nephrologist workforce, it's not like you can solve this easily with more bodies because you just don't have more folks to do it.

I think about how I became interested in nephrology, which is that as a fourth-year medical student here at UT Southwestern here in Dallas, where we are, I did a rotation. It was a nephrology rotation with an attending who was incredibly inspiring. Bob Toto is known as, you know, a real giant in nephrology. He was a PI on many trials and, even just on the rounding in the hospital level, he was an incredibly inspiring attending.

I think what we really need are folks like that who will dedicate their time to be involved in training programs and really show trainees the value of nephrology and how interesting it can be. I think it feels very intimidating to a lot of medical students and internal medicine residents. And I tried really hard when I was on service with medicine residents to just bring it down to the basics: What are we here for? What can we manage? You know, it doesn't have to be this intimidating subspecialty, but I think it's very much viewed that way.

Dr. George Hart: I think you're right. I mean, what was very attractive to me was this continuity relationship that you built over time, very similar and analogous in a lot of ways to primary care, particularly as nephrologists sort of assume our primary care role later in kidney disease. I too kind of fell in behind a mentor who was really inspiring and that's a challenge, I think in all of healthcare today, is having mentorship and creating relationships but I think those are great ideas.

Competition from hospitalists?

Dr. Julie Dominguez: I think part of the problem is that lately, turns out, education's not cheap, and a lot of residents are exiting medical school with high educational debt. They may even have educational debt left over from college. I saw trainees who were anywhere from a quarter of a million to half a million dollars in debt at some of the programs where I worked.

And the problem is, as a first-year hospitalist, so you finish internal medicine residency training, you can get a hospitalist job right away. The entry salary for that is I would say four to six times what a nephrology fellow is going to get paid. So you're asking somebody to defer paying off all of this debt for another two to three years, depending on the nephrology training program. You know, and the economics of it are, it's just difficult. People have kids, you know, during training, they've got lives that they want to start and asking them to take two more years, three more years, of training at fellowship-level salary when they're already underwater a quarter of a million dollars, that's a hard sell.

Dr. George Hart: I mean, I think you're right and I think it speaks to why, you know, we need to think of alternative solutions to how we're going to provide care. And I think what you've been talking about and addressing is really important as the prevalence of kidney failure patients continues to rise across the country.

Last question, not to put you on the spot, and I see your crystal balls down on the floor, what are some of the major innovations and developments that you think we can look forward to here in the next three to five years?

Dr. Julie Dominguez: That's a great question. I think the first one that comes to mind is that I do think that value-based care is here to stay in kidney care. CMMI has given a very clear message that they're hoping to certify the CKCC Model. They're coming out with another model, the IOTA Model, which is really related to transplant, but again stays in that kidney care sphere. And so I do think that value-based care is here to stay in kidney care.

I think the really interesting question is what's going to happen over the next three to five years. We've seen a lot of iteration even in the first three years of the program now with CMMI, and I think it'll be interesting to see where this starts to go and what sorts of patient reported outcome measures and other things get involved in the program.

I think another innovation coming down the pike in the next three to five years is really how we think about and how we utilize some of these newer classes of drugs like SGLT2 inhibitors and GLP-1 receptor agonists. You know, we've got a lot of evidence starting to come in about their benefits in CKD patients for slowing progression for reducing proteinuria, improving kidney outcomes, and reducing hospitalizations. We also know that these drugs have significant impact for GLP-1s in patients with obesity and for SGLT2 inhibitors for patients with heart failure and cardiovascular disease.

We all know that this diabetes-kidney disease-cardiovascular disease trifecta affects a lot of patients. I think it'll be interesting to see whether we start seeing combination drugs, second generations of these medications that minimize side effects but continue to improve outcomes. I think that's a space that's really, you know, novel therapeutics is a space that's really ripe for the picking right now.

I think a third area that we're really starting to see more and more innovation is transplant also, right? We just had xenotransplantation, there were two patients who received pig kidneys. We've had new therapeutics that have come out in transplant in terms of immunosuppression. And so I think that that's an area that really may have a lot of movement here in the next three to five years.

And I already mentioned the IOTA program from CMMI, which is really looking at improving access to care and access to transplant for patients. And so I think that that's another area, not just the therapeutics and the xenotransplantation, but also improving access to care in the transplant space.

Dr. George Hart: Yeah, those are great insights. I mean, I hear from you a sense of optimism. Is that fair?

Dr. Julie Dominguez: I am, you know, after what I would view as a couple of decades of not necessarily stagnation in kidney care, but not necessarily a whole lot of movement in terms of are we doing dialysis really any differently? It's really a lot of non-inferiority trials in the majority of these. We don't really have new classes of therapeutics since ACEs and ARBs came out in the late ‘90s, early 2000s, you know, we really hadn't seen a lot of movement in kidney care.

And now all of a sudden we've got these major new classes of therapeutics. We've got advances in transplant. I really think that this is a good time for nephrology, and I hope that this is—you know, to go back to the question that you posed about how do we get more folks interested—I hope that this is something that looks really interesting and exciting to trainees and that we get some revitalization of the nephrology workforce.

Dr. George Hart: No, I think you're right. I mean, I'm excited to see where this is going to go in the next five to 10 years and it does seem that after a period of working behind the scenes to create opportunities, we're now starting to see that come forth.

Julie, it was great to have you here today. Really appreciate your insights and all the effort that you're putting at Interwell. And in fact, it's under your leadership that we are trying to address and solve these issues.

For more conversations on improving care for patients living with chronic kidney disease, subscribe to Kidney Health Connections. You can also find us on our website at interwellhealth.com.