Podcast - Supporting Physicians in the Transition to Value-Based Care

This episode of Kidney Health Connections explores how to support physicians in the transition to value-based care. Sharing his perspective shaped by decades of experience in nephrology and healthcare technology, Interwell Health Senior Vice President Dr. Terry Ketchersid walks through the wins and hurdles nephrologists have experienced over the last decade, and the importance of creating incentives that work in both fee-for-service and value-based care models as practices navigate this evolving landscape.

During the conversation, Dr. Ketchersid discusses how value-based care programs become “the tide that's raising all boats” as practices translate strategies such as comprehensive patient education across their patient populations. As the co-leader of Interwell's Acumen Epic Connect electronic health record, he also touches on the value of data analytics, spotlighting the role of EHRs in streamlining workflows and enabling better patient outcomes, and the importance of distributing best practices to ensure more physicians can succeed on the road to value-based care.

Transcript

Dr. George Hart: Hello, everyone. Nephrologists are not optional, but foundational, to how many of us envision the future of value-based kidney care to be delivered. Amassing a large network of like-minded providers creates all kinds of opportunities. Yet, a successful transition from fee-for-service to value-based care requires more than just an army of nephrologists. It requires a change of mindset, of culture, with a renewed commitment to new workflows and learnings, new tools to help drive change.

We're joined today by Dr. Terry Ketchersid, the senior vice president of Interwell Health to discuss the key drivers of value-based care happening within a physician practice and how the EHR can help physicians provide better care for patients. Terry, it's always a pleasure to speak with you and welcome to the program.

Dr. Terry Ketchersid: Thank you, George. My pleasure. I'm looking forward to the conversation.

Dr. George Hart: Terry, I don't know of anybody that's had the front row seat with the evolution of value-based care the way you have, but you weren't always involved in value-based care. Give us a little bit of an idea of how the early career that you had put you in a position to really be able to contribute and how it contributes today to how you help physicians and practices navigate these waters.

Dr. Terry Ketchersid: Yeah, happy to. It's been a long, winding road and I think I've shared some of it with you before. So I practiced nephrology for 15 years or so, uniquely though in three different locations. And those different locations gave me different perspectives. What's it like to be in a big practice. What's it like to be in a small practice, in a rural practice.

After that, I was invited to step away from the practice of nephrology by a close friend and mentor and began working with one of the original electronic health records, initially the Gamewood Healthcare Network that we all know today as Acumen. I had the opportunity to spend about five or six years as the chief medical officer for that EHR, and that allowed me to travel the country trying to convince practices that they really ought to think about becoming Acumen users.

Later, Fresenius acquired that company and then I got a different perspective about the landscape. I spent some time with the Fresenius information technology group, and I developed a perspective from the eyes of the dialysis provider.

And then, about 10 years ago, the value-based care journey began. I became the chief medical officer of what Fresenius called the integrated care group. And again, there was opportunity to travel the country and meet a large, large number of nephrologists and understand the different challenges that they faced.

Dr. George Hart: And maybe take a step and remind everybody what was the mission of why Interwell was originally created.

Dr. Terry Ketchersid: Yeah, it's a great point. So 2019, the Advancing American Kidney Health initiative gets launched by a former president and our current board member, Secretary Alex Azar. And there was a recognition—we had been through the ESCO program, and we began to develop an understanding of value-based care.

But then this idea coalesced around what could we do differently that would impact nephrology practices as they were making this transition to value-based care. And this synergy between Fresenius Medical Care and large nephrology practices in the country came to fruition.

And then you and I were recruited to go out and expand this network and we thought we were going to jump on airplanes and shake hands when the COVID pandemic began. And we actually pivoted and were able to successfully build that network virtually, which I would have thought, frankly, would have never been possible, but it worked.

Dr. George Hart: And one of the ideas—and yeah, you and I had side by side seats on that bus—one of the things that was quickly recognized is even the most sophisticated nephrology practices didn't have the wherewithal to be able to put together the analytics, the data, and everything that's required. So you really need a partner, right?

Dr. Terry Ketchersid: Oh yeah, you definitely need a partner. And you need to recognize that the practice of nephrology has changed in our careers, right? You and I are of the same vintage, if it's okay to use that word. I distinctly remember the first practice I joined in the early ‘90s. The expectation was that we saw every patient every day that they dialyzed in an outpatient clinic. If they made their way to the emergency room, we went to the emergency room. If they needed to be admitted, we admitted them. They needed to be admitted to the ICU, we admitted them at the ICU. So what I'll call the scope of practice was substantially different then.

You fast forward to today, and the pendulum has sort of swung the other way. And I think there's probably two critical things that happen between now and then that created that shift in scope of practice. One was the fact that the residency programs around the country decided that doctors in training were spending too much time in the hospital. So they substantially decreased the number of hours physicians in training could spend.

And about that time became the emergence of the hospitalist world. So all of a sudden you're in an environment where I don't have to admit the patients, there's somebody there, I can act as a consultant. And suddenly the scope of practice shifted to, “I'm going to focus on caring for the dialysis treatment and just the nephrology problems and there will be somebody else to take care of the rest.”

One of the things that value-based care has done is begin to shift that pendulum back the other way. We're not expecting physicians, necessarily, nephrologists, to be treating depression, or diabetes, or chronic obstructive pulmonary disease. But in models where we're both taking total cost of care risk, in a value-based care program, it's important for somebody to be the principal care provider. And if not managing those problems, help us understand who might manage them.

Dr. George Hart: I mean, I totally agree that this transition away from primary care physicians going to the hospital, the rollout of hospitalists, the separation and isolation, if you will, between providers has contributed and maybe led to a fragmented healthcare delivery system. And returning nephrologists to being the cornerstone of care seems just a logical way to approach the future. But fee-for-service in and of itself inherently seems unable to address some of the needs of patients as we see them today. Value-based care offers some advantages in that regard. And can you elaborate a little bit for us on what those advantages are?

Dr. Terry Ketchersid: Yeah, absolutely. You know, the way people begin to think about value-based care, if you are in a position to do well when outcomes are better, especially in a total cost of care model, you can think about value-based care as creating a funding mechanism to buy things that you and I could never afford in fee-for-service.

Take renal care coordinators for example. There is no financial model in fee-for-service that incentivizes the resources necessary to be with patients when I'm not in front of them or you're not in front of them. Resources that, by the way, are helping those patients navigate decisions that otherwise might be made to their detriment.

So there are a lot of things like that. Kidney disease education—the delivery of kidney disease education—is challenging. But in an environment where things like optimal starts are substantially rewarded, there becomes yet again another funding mechanism for resources that you and I just wouldn't have access to in fee-for-service.

Dr. George Hart: We all have scars from the past 10 years of value-based care and this transition that everyone's trying to make. There are some victories in some things that are happening, yet still a lot of challenges. Why don't you, if you would, start with some of the victories that you see that we've had here in the past 10 years, but also point out where we're falling short and what we need to work on.

Dr. Terry Ketchersid: So the victories, I think specifically we mentioned optimal starts. So unfortunately, a small percentage of patients with advanced kidney disease are going to develop end-stage kidney disease. Historically, there's not been an opportunity to coordinate the care, the really remarkably complex journey, that those patients require. We've seen dramatic increases in optimal start rates in our value-based care programs. That's fantastic for patients, it's fantastic for their total cost of care.

The other transition that historically has been challenging is the transition from an inpatient stay to an outpatient stay. When patients come out of the hospital, their risk of going back into the hospital is substantial.

Focusing value-based care resources to help that patient get in front of a provider—which we know when that happens, substantially positively impacts the 30-day readmission rate—is something that's just not incentivized appropriately in fee-for-service.

Those are some of the wins. I think some of the challenges, if you think about value-based care at its core, one way to just dumb it down, it's sort of about the financially efficient delivery of quality. In every one of the value-based care programs we're involved with, there's an intersection between cost of care and quality. And that's an important intersection, right? I mean, not that you and I would ever do this, but if you wanted to drop the cost of care in a dialysis population, just start dialyzing everybody twice a week. Well, you know, quality would drop like a rock. It's not just about reducing cost; it's about reducing cost and at least maintaining or improving quality.

The challenge in some of these programs is you have to pick the right quality strategy. You have to make sure that the quality measures that you are incentivizing are the ones that impact cost of care. Because once you publish that quality strategy, a lot of people are focusing on that. Sometimes that can lead to unintended consequences. Sometimes it can lead to not focusing on other things that matter.

I think the second opportunity that's still out there is the intersection between primary care and specialty care. So, you could take a dialysis population, and you could make the case that nephrologists and dialysis providers are well suited to manage the total cost of care. As you move into CKD, and especially as you move well upstream in CKD, you can make the case that stage 3 patients are complicated primary care patients whose heart failure and diabetes are just that much more difficult to take care of because they have some impaired kidney function. And figuring out how to create that collaborative opportunity and allocate the financial success appropriately is something that's not quite fully baked just yet.

Dr. George Hart: But I think it's an opportunity. And I totally agree with what you just said about primary care and going further upstream. But I think it's—you know, we're sitting here in Wisconsin, we are miles away from the Epic headquarters—and everything you describe to me seems imminently solvable with the help of a sophisticated EHR that breaks down these silos. And I think Acumen Epic Connect starts to do that. Am I thinking about it correctly?

Dr. Terry Ketchersid: Oh, I think so. EHRs have long been beaten up appropriately as financial billing tools. But the instance of Epic that we operate today creates clinical workflows that are easily embraced—not just for nephrologists, but for their advanced practice providers. Delivering clinical decision support at the point of care, being able to look at a population of patients and find the outliers.

Actually, the patient portal, MyChart, in Epic is easily the most commonly used patient engagement tool in the country. There are a lot of opportunities, particularly with the single instance of Epic.

And I want to get back to something you mentioned just a moment ago. The interesting thing about value-based care today is almost all of the models that we participate in, with rare exception, sit on a fee-for-service chassis. And so the vast majority of the revenue coming through the front door of a nephrology practice is still coming from fee-for-service. Part of our secret sauce, and it's probably not much of a secret, is we have figured out ways to create incentives that work in parallel. Things that are wonderful in fee-for-service, but have a huge collateral benefit in value-based care.

Interwell Learning might be the poster child for that. You have a fantastic kidney disease education tool. It's relatively easy to use. It's integrated into Acumen Epic. There's a financial fee-for-service payment to the provider that's delivering it. It's very clear when it's delivered appropriately to patients that optimal start rates go up. It works in fee-for-service. It works in value-based care.

Dr. George Hart: Yeah, I mean, that makes total sense. You in the role you have now, and in the roles you've had in the past, have traveled the country. For those of you that are a little bit older, I would say Terry is the Charles Kuralt of nephrology—been everywhere. And in your current role with Acumen, you have the ability to meet with these practices today, go into the practice, help optimize what they're doing. What are some specific examples of things that you're finding and how you're helping?

Dr. Terry Ketchersid: Great question. Let me start by highlighting a couple things. So let's say you're a practice in, well, let's say Madison, Wisconsin, and you're taking care of patients that happen to be in 4 or 5 of the value-based programs we operate. You know better than I that there are no two of those programs that require us to pursue the same quality strategy. But if we came to that practice and said, “You know what, for these 10 patients over here, I want you to execute these five quality measures. And for these five patients, I want you to do these three other measures.” They would look at us kind of funny and they'd kind of walk away.

So one of the things we've done is step back as an organization and said, “What are the two or three things, that if we could get practices to do more of, patient outcomes would improve and total cost of care would go down?” When we've deployed those metrics, what we've been able to do is find practices that have performed really well.

And so some examples of that, if you think about [what] we mentioned earlier, if a patient comes out of the hospital, 30-day readmission rate on the dialysis side is about 30 percent; on the CKD side, a little under 25 percent. So if I'm a dialysis patient, I come out of the hospital, there's a one in three chance I go back into the hospital in 30 days. Unless, I see a member of my care team. And our data analytics folks have told us exactly what that impact is. So if those patients coming out of the hospital have a visit with a provider within 14 days of discharge, the 30-day readmission rate drops by 25 percent. That's great for patients, it’s a reimbursable service in a fee-for-service world, and it reduces the total cost of care. And it really doesn't matter which quality measures payer X or payer Y are asking us to pursue, because they are total cost of care programs.

Dr. George Hart: For that to be successful and to actually happen, you have to influence physicians in a way that they change their workflows and behavior.

Dr. Terry Ketchersid: Yes.

Dr. George Hart: Are you finding that physicians, now that we are four, five, six, seven, eight years into value-based care, are more malleable in that way and amenable to changing their behavior than they might have been in the beginning?

Dr. Terry Ketchersid: I think the answer is yes in some parts of the country, and it's getting to yes in other parts of the country. I've heard comments from physicians related to both the post-discharge transitional care follow up and kidney disease education—specifically kidney disease education—say, “That's exactly why I went into medicine. I've got an opportunity now to do what I really wanted to do.”

And the workflow changes. The neat thing about this is the practices that are doing it well, they're doing it for all of their patients, not just their value-based care patients. These value-based care programs are turning into the tide that's raising all boats.

And it's actually not just the physicians. You get a strong practice manager. You get a practice that understands the benefit of having a sophisticated advanced practice provider workforce. The workflows actually can change and impact the non-physicians in the practice and get the practice to the point where it needs to be.

Dr. George Hart: Well, I think you and I agree that advanced practitioners offer a solution to a lot of problems, including the nephrologist workforce shortage, as well as the ability to carry out protocols that are influential in being successful in value-based care.

We've talked about the value of nephrologists and providers in the value-based care movement, the need for an EHR and how it can deliver and break down some of the barriers. What other lasting issues, Terry, do you think that we can help nephrologists with to help move them toward value-based care and, like you said earlier, get back to practicing medicine the way many of us want to practice?

Dr. Terry Ketchersid: Great question. I think there are two or three things.

The first is frankly listening. You and I have discussed before the benefit of actually visiting practices, actually shadowing them, watching them in their workflow. Kind of understanding, as we both have walked in their shoes, understanding what the actual barriers are, as opposed to showing up and telling them, “This is what needs to be done.”

I think the second piece of this is communicating and distributing best practices. I think one of the biggest advantages to the KCE medical director forum calls that we have is the nephrologists now know each other, and they'll find out that practice XYZ has figured out optimal starts, or they have figured out CKD visit frequency, or chronic condition review, and they'll pick up the phone and call them. So communicating best practices I think is a critical piece.

And last but not least is just being vigilant to continue to identify either solutions or services that work in both worlds. I think we're years away from the world being all value-based care and we have to find ways where we don't completely blow up the practice's workflow in the name of value-based care.

Dr. George Hart: Yeah, totally agree and sort of feel like we have a responsibility now that we are the valued partner for many of these nephrologists and have this common interest with Acumen and the ability to create workflows and make better opportunities for our patients and our other aligned partners.

Terry, we could do this for hours. In some instances, we actually have. It's nice to have you here today and to hear your thoughts and hope to do it again sometime.

Dr. Terry Ketchersid: George, I appreciate it. It's been my pleasure. Thanks for the invitation.

Dr. George Hart: Perfect. If you haven't already, subscribe to Kidney Health Connections on the listening app of your choice for more conversations with the leaders and innovators in value-based kidney care.

For more information on how Interwell is driving improved outcomes and lowering the cost of care, visit our website at interwellhealth.com.