Podcast - Creating a Sustainable Future for Value Based Kidney Care

Former Secretary of Health and Human Services Alex Azar joined Kidney Health Connections to reflect on the shift to value-based care and share his predictions on the future of kidney care in the United States.

Alex Azar, former secretary of Health and Human Services (HHS) and a board member at Interwell Health, joined Kidney Health Connections to share his personal connection to chronic kidney disease (CKD) through his father’s experience and reflect on the aims and impact of the Advancing American Kidney Health (AAKH) initiative he spearheaded. Azar explains how value-based care models aim to improve CKD management by fixing incentive structures and rewarding quality outcomes—including slowed CKD progression, increased optimal starts, and higher transplant rates. He also offers his predictions on whether the new administration will continue to support the ongoing shift to value-based kidney care.

This episode explores key topics including how the laws of economics have shaped our current healthcare system, Medicare’s influence on healthcare payment models, and the growing pains that come with large-scale healthcare transformation. With a focus on early intervention, patient-centered care, and innovative technologies, Azar shares his optimism for the future of kidney care in the United States.

Tune in to this insightful discussion for an in-depth look at the policy decisions in the making, the tangible benefits already taking shape, and how these shifts impact patients, providers, and payers.

Disclaimer:

The statements contained in this podcast are solely those of the participants and do not necessarily reflect the views or policies of CMS. The participants assume responsibility for the accuracy and completeness of the information contained in this podcast. 

Transcript

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: In my role at Interwell Health, I spend a lot of time wondering, “How can value-based care deliver on its promise to transform healthcare? And are we on the precipice of a value-based future in the world of nephrology?”

In today's episode, we're going to sit down with Alex Azar, former Secretary of Health and Human Services. Secretary Azar was a key architect behind the Advancing American Kidney Health initiative, and he now serves as one of our board members at Interwell Health. Drawing on Secretary Azar's vast experience and efforts to champion value-based kidney care, we'll explore the challenges which are slowing adoption and learn how we can foster innovation to transform healthcare.

But before we get started, I do want to remind everyone that because we're discussing some of the government valued payment models, we just want to clarify that the statements contained in this podcast are solely those of the participants and do not necessarily reflect the views or the policies of CMS. Interwell assumes the responsibility for the accuracy and the completeness of this information contained in the podcast.

Secretary Azar, thank you again for joining us today. There's a lot for us to talk about and unpack, but I think it's really important for this audience to know that for you this isn't just business, this is actually personal in your connection to kidney care. And I'd love for this audience to get an understanding of that perspective, and maybe have you sort of share how you came to have such a passion for kidney-based care.

Alex Azar: Well, great. Thank you, Dr. Hart, for having me on the podcast. And yes, I not only come at the issue of kidney care as a vitally important aspect of how we run our healthcare programs in the United States—you know, spending one fourth of every dollar in Medicare related to chronic kidney disease—but from a personal perspective. My father, who was a very prominent ophthalmologist, he ended up having kidney disease and we as a family went through the entire continuum of chronic kidney disease.

So I got to see firsthand the initial crashing into dialysis. I got to see the center-based dialysis and the toll that it took, the disability basically that it forces—can often force—on people because of the ups and downs of getting dialyzed and then recovery and then, as soon as you're feeling up to it again, you're going back in and having your strength sapped away from you. And then discovering home-based dialysis, peritoneal dialysis, and the very important change in quality of life that that brought. Then a living donor and going through the transplant of a kidney, the eventual failure of that kidney. And my father actually died while in the intensive care unit doing dialysis back in 2020.

So, we saw the whole continuum of what chronic kidney disease is like, what works, what doesn't work in the American system. And a lot of that really helped inform the kidney, the America's Kidney Care initiative that I helped lead in the Trump administration.

Dr. George Hart: Well, you know, having seen the journey of many families, I can appreciate what you went through and how you partnered with your father in that journey and appreciate the fact that it informed you and how you spearheaded the Advancing American Kidney Health initiative in 2019. Maybe again, let's go back in time and maybe you can explain what were the objectives that you were hoping to achieve with that initiative.

Alex Azar: So George, I do a lot of teaching right now at universities. And before every—at the beginning of almost every class that I teach—I start by saying, “Listen, healthcare goods and services are economic goods and services. And if you do not respect the fact that healthcare goods are economic goods and that they will follow economic laws, you will be sadly mistaken.”

And what are economic, what is a core economic law that dominates healthcare? Well, if you pay for something, you get more of it. So if you pay for center-based dialysis, you're going to get center-based dialysis. If you pay for home-based dialysis, you're more likely going to get home-based dialysis. If you create financial incentive structures to delay the progression of chronic kidney disease, you will get efforts that actually arrest the development of CKD. If you have incentives to transplantation, you will get more transplantation, et cetera.

So much of the system, really, this isn't that people are bad actors or anything, just these are economic goods, and the system reacts to economic laws. And so what we saw was that in the United States, most people were getting center-based dialysis, not home-based dialysis. We have a transplantation system that doesn't serve the patients well, that didn't have adequate incentives to ensure that we were collecting quality organs, even ones that might not be perfect, and incentivizing the use of them in transplantation.

So my father, as I said, was a very prominent eye surgeon. He was an adjunct professor at Johns Hopkins. So you know, certainly au courant, very much in at the top of the game in the medical profession, but it took us years before we actually were well-educated about the availability of peritoneal dialysis. And that was just, that radically changed his quality of life being able to be at home at night, plug in, have eight hours of dialysis and not have the, you know, the ups and downs that I referred to before of center-based traditional dialysis.

Think about that for somebody who, you know, at the time was former deputy secretary of Health and Human Services, ran Medicare, president at Eli Lilly in the U.S. here, and then eventually as secretary, I mean even that knowledge base. So imagine for people who aren't at the pinnacle of the healthcare profession and healthcare policy world getting that information out there. So that was really what was behind it.

So what we did in designing the kidney care initiative was try to fix those incentive structures. Reward practices that enter into the models that can slow the progression of CKD. Reward practices that are able to prevent crashing into dialysis, but rather ensure a smooth planned transition into dialysis if it actually becomes necessary. Reward practices that are able to get their patients on the transplantation list, and perhaps even leapfrog over center-based going on dialysis—that would be the ultimate goal, would be to move eventually from CKD progression right to transplantation. Reward transplantation. Fix the organ procurement system that we have in the country, so really getting at the organ procurement system and organ allocation system that we have. And so make all of those incentive changes and structural changes to hopefully fundamentally change not just the patient experience but also the quality of outcomes in terms of kidney care in the United States.

Dr. George Hart: You're certainly speaking music to my ears as a nephrologist who spent the majority of my career in fee-for-service models and running up against the roadblocks and the increasingly siloed system that healthcare has become.

You know, I'm excited at the changes that are coming, and I think 2019 was a pivotal moment in the evolution of value-based care, returning nephrologists to being the centerpiece of how attribution of patients was going to occur. We're certainly starting to see some exciting outcomes: optimal start improvements, better CKD management, some delays in progression. The private payer world is certainly taking notice through Medicare Advantage. And with the movement of patients away from traditional fee-for-service into Medicare Advantage, there's some momentum there.

Some would say that progress is lagging. What is stalling this broader adoption, and you know, what are some of the challenges that you see that we need to overcome to get better adoption?

Alex Azar: Yeah, so I do get a little frustrated when I hear complaints about the speed of progress. Because remember, the changes that I put in place in 2019 are literally the first fundamental changes to how we deliver and pay for kidney care in the United States in 50 years, five-zero years.

So we have an entire system built on fee-for-service, paying for procedures, incentivizing center-based dialysis, okay. It is one fourth of Medicare spending, CKD and complications connected to CKD. So you're talking about rewiring a huge part of the Medicare system. And started in 2019, we had this little thing called COVID that somewhat delayed the progress of implementation of the program. And so we really didn't even get things started until about 2021 and parts of the program not even till 2022.

And so, you're talking about this massive change in the system. And early on, say in the first year, year and a half, a lot of this is simply getting patients attributed to practices that are willing to take financial risk for their care, getting those practices to actually be able to connect with those patients. Because, as I'm sure we'll talk about, the name of the game really is those points of connectivity, those interactions to get people into the system.

And yet, even in the first full year of the program, CMS found that we are starting to make progress here. So I'm going to just look at notes because I do want to be careful given that we're talking about actual data, but in the first year of the program we saw significant improvements in home dialysis. We saw more people on the transplant wait list. We saw better screening for depression, we had smoother transitions into kidney care. Some of the participants actually were able to deliver lower cost in addition to these quality improvements that I just referred to.

The top 17 highest performing entities by quality score in the entire program were Interwell providers. And the only three that achieved a perfect score were Interwell providers. We also had the most gross savings at a higher-than-average savings rate across all participants. And we saw a significant increase in the rate of optimal starts across our program, which is that smoother transition into dialysis, more at home dialysis, but in a way that avoided unnecessary hospitalizations and crashing into dialysis.

And that's just in that first year of the program alone when you're still even getting to know your patients and, in some instances, you know, still trying to learn from CMS who is being attributed to you. And still, we and others are delivering, I think, really good results in just that first year of the program.

Now private payers. So Medicare fee-for-service really is, might call it the thought leader, the game changer in how we pay for things in our healthcare system. Why is that? It's because individual private payers just don't have enough market concentration and power in any individual market to drive significant change. They count on Medicare fee-for-service as the big dog in any market to be able to drive that change. And then the private payers are fast or slow followers of those changes.

But we're seeing that now. We at Interwell are seeing it, I'm sure others are seeing it, where private payers are saying, “We want to move to those same different incentive structures.” We're actually even seeing some interest in private payers of can they even push further upstream in CKD. Because really the American kidney care initiative is focused primarily on CKD 4 and 5. But now payers are starting to look and say, “Can we even incentivize progression to address CKD 3 level?”

So I'm excited about where we're going. This clearly is the direction that kidney care is going to be heading in in the future. I don't see us going backwards. It's right for the patient, it's right for the system.

And I think it's just a matter of, you know, how quickly can we get there, but doing so in a way that keeps the patient at the center of the program and makes sure we're delivering quality outcomes for patients throughout.

Dr. George Hart: You've mentioned a couple of things, and I have to agree with you as I sit in conversations that we at Interwell are having with payers. Although originally focused on the dialysis population and late-stage CKD, there's certainly a pivot toward earlier stages and how do we slow the progression of disease and affect patients on a broad scale over a long period of time.

There are some plans that actually think they can go it alone in value-based kidney care. Others are partnering with companies like ours at Interwell. I mean, help our listeners understand what would be the pros and cons of either approach and what would influence a healthcare company to try and go it alone versus partnering with another provider.

Alex Azar: I honestly don't know how as a private payer you could effectively go it alone and think that you could essentially virtually manage this very, very complex population and do the types of interventions that are required.

Listen, there always are some low hanging fruit, like trying to get people educated about and transition to home dialysis rather than center-based dialysis. That's one of the, you know, easier interventions. Trying to get people on SGLT2s, make sure they're on other appropriate pharmaceutical interventions that can help with disease progression.

But that being said, to get to the—when you move away from the lower hanging fruit—to get to the really deep types of change that you need in terms of patient physician interaction and care delivery, I don't know how you do that from a payer without deeply, deeply connected integrated physicians. And of course, as you know, when we're with this patient population, it's the nephrologist at the center. The nephrologist becomes—I saw this with my dad, and I think it's generally the case, you could confirm or deny—I think the nephrologist becomes effectively the primary care doctor and the care coordinator for our later stage CKD patients.

And so I think the toolkit that's needed is a very robust one to deliver these results. You need first, as with any value-based care, you've got to be able to have really good information about who your patients are so that you can focus on those that require the more frequent interventions and more frequent interactions. Who are the folks that are going to be relatively, with education and more limited interactions, be able to largely be put on the right path? And who are the folks that are going to require those 12, 13, 14 touch points and interactions per year in order to make sure that they that they're on the right path for quality care delivery? So you need to have really good information.

Then you need to have practice extenders, those critical players in addition to the nephrologist, because of course our nephrologists are such a scarce resource. You have to build around the nephrologist those other players: nurses, nurse practitioners, PAs, et cetera, maybe even social determinants of health people to really get the package around folks so that you can get them on the right course of treatment and living to slow down the progression or to advance them into transplantation.

As part of that information that you need and the ability to manage care, we have found that having a nephrology specific electronic medical record—we've got one called Acumen through Epic—that we find absolutely critical to us to be able to ensure that we, across our system of 2,000 nephrologists, are able to really coordinate care and to know our patients well. But that has very much a focus on kidney disease as opposed to more generic records models.

You need to have physicians that are incentivized too and get what we're trying to do in value-based care. And that's where, again, I don't think a private payer standing at arm's length can really integrate into the nephrology practices the way a value-based care organization like Interwell can do providing basically best practices, replicable practices, using Acumen as a tool through the EMR to help our physicians practice at the top of their skill level in delivering quality care in a value-based way for CKD. Then sometimes, of course, you do have situations where there are folks who just can't get out of a procedure-based mindset and they might decide they want to practice different place, different way.

But I think that toolkit of knowing your patients, best practices, centers of excellence, electronic medical records, the right physicians, core concentration of nephrologists, practice extenders—those are all things that don't happen by accident, and I think would be very hard to develop just at a payer level without the providers themselves having skin in the game and the right incentive structures.

Dr. George Hart: So, you and I are clearly all in on value-based kidney care. We've each made decisions, and you've had an opportunity in your public service to have a huge impact on how we view this and how the model's evolving.

However, look, let's face it, it's a new day in Washington and there's new leadership. Just in March, CMMI announced that it will end the ETC model early, which was a mandatory model focused on improving access to home therapy and transplants. Other programs are going to end early as well. I mean, is the government still going to support value-based care models as strongly as they did back when you were with HHS?

Alex Azar: Well, I think they will. And listen, there's always useful pruning at CMMI. The whole point of demonstrations is you try things, and you want to fail fast, and you want to move on. There's a renewed commitment from CMS where they really want to show cost savings out of the different models and programs. And again, I think that kidney care is absolutely ripe for demonstrating and delivering cost savings.

I hope they'll focus on how do we improve it, how do we expand it, make it even better? But again, you know, when I get people complaining about CMMI or value-based care, I say to them, “What's your alternative? Go back to fee-for-service? Like really, that's your answer is go back to the glory days of paying for procedures?” No, that's not going to happen. What you might find is just different points of emphasis.

Listen, I was the secretary, and I was there at the founding of the move to value-based care under Secretary Leavitt, I was his deputy when he first really set us down on this journey to value-based care. And when I came in as secretary, it was one of my four key priorities that I drove personally as secretary and I said, “We're burning the boats. We are never going back to fee-for-service. We just need to move faster to value-based care.”

Where does that leadership come in the new administration? To be determined, you know, who really wants to push it, drive it. But it has its own momentum, simply out of necessity, as I said, because we're not going back to fee-for-serve. I've not heard, I mean, I haven't heard any very thoughtful person connected to healthcare, healthcare policy, regardless of their politics, say, “Boy, we just got to get back to paying for procedures and fee-for-service. This value-based stuff is just terrible.” You don't hear that.

Dr. George Hart: The analogy of nephrologist and maybe healthcare companies having, you know, one foot in a canoe that's fee-for-service and the other foot in a canoe that's value-based care is appropriate. I personally think that it's hard to get traction with nephrologists until this becomes way more of a larger piece of their economic pie, if you will. Is it enough just to see sustained savings or, I mean, do we need certification of the KCC Model? What really will be that point of no return for us?

Alex Azar: At some point what CMS has to decide is: we know enough. We know enough that this works, that this is the way of the future. And just do it. And just say, “This is how we're paying for kidney care from now on,” and drive that forward.

Now listen, we're still learning, okay? We're learning about the different risk models. There are several different models that I created in terms of the level of risk that practices can assume and we're seeing which ones have tended to work, which ones haven't worked. We definitely are learning about a lot of the challenges around the data systems and the data interchange. We've seen significant challenges regarding just the payments and predictability of payment structures given the formulas that are used around trend and risk adjustment, et cetera. Those I think are all still growing pains that perhaps merit a bit of continued maturation.

That being said, I have been out there publicly saying with regard to CMMI and value-based transformation, at some point we just have to pull the band-aid off and just say, “This is what we're doing.” Like no more models, no more demonstrations, it's just how we're doing it. And that will take top-down leadership to really force that. It'll take commitment that they're seeing quality of results, and the systems are in place to enable it. But I think that that day will come.

Dr. George Hart: This has been great, and I've certainly learned a lot listening to you today. Are there things I've left out that you'd like to share? What does your crystal ball tell you?

Alex Azar: So I am, I actually personally am optimistic for the future of kidney care for patients. I think there are challenges ahead. I think that we need to figure out access to nephrologists. We need to figure out how do we care for people at earlier stage CKD when we just don't have enough nephrologists to take care of everybody in CKD 1, 2, 3. So how do we get appropriate care to those patients? Through primary care models that incentivize especially the pharmacologic interventions that are needed early on there that could really help arrest progression of disease, but that primary care physicians may not be as attuned to focus on as a nephrologist would be. So how do we integrate primary into nephrology?

But where I get really optimistic is on transplantation. I get to see—this is one of the benefits of being a secretary, or former secretary—is I get to see a lot of technologies. We are not there yet, but I think it could be in my lifetime that we see a day of unlimited supply of organs for transplantation through, so, alternative means other than just cadaveric transplant. Whether it is, you know, genetically modified pig kidneys, whether it's 3D printed kidneys, you know, just the technology and the changes that are coming could really revolutionize care.

Dr. George Hart: Well as a recovering transplant nephrologist, I couldn't agree more. And you know, your comments on xenotransplantation take me back to my days in fellowship and an immunology lab where it was already being talked about. Now that was quite a while ago, but we're getting there. We're getting there.

Listen, this has been amazing and outstanding, and I really can't thank you enough for joining us today. Just to have someone with the experience you bring and the knowledge you bring is just a great asset to Interwell and to our board. And just thank you for all your commitment there and for having the time to join us today.

Alex Azar: Thanks, George. Good to be with you.

Dr. George Hart: And for our listeners, we hope you'll continue to join us for more conversations on the future on kidney care by subscribing to Kidney Health Connections on the listening app of your choice and visiting our website at interwellhealth.com.