Proven Strategies for Value-Based Kidney Care Success

Understanding value-based care for chronic kidney disease patients and the KCC Model

Value-based care, unlike traditional fee-for-service models, prioritizes long-term health outcomes over the volume of services delivered. In nephrology, the shift away from traditional fee-for-service has never been more critical given the high costs of treatment for chronic kidney disease (CKD) and its immense impact on patients’ lives. Value-based care ensures that quality takes precedence over quantity, emphasizing long-term health outcomes rather than episodic interventions.

The Kidney Care Choices (KCC) Model, launched by the Center for Medicare and Medicaid Innovation (CMMI) in 2022, represents a bold step toward value-based kidney care that incentivizes healthcare providers to focus on improving patient outcomes while reducing overall costs. The Centers for Medicare & Medicaid Services (CMS) is currently evaluating the pilot program to inform the next evolution of the Model, which currently runs through 2027.

Disclaimer: The statements contained in this article are solely those of Interwell Health and do not necessarily reflect the views or policies of CMS. Interwell Health assumes responsibility for the accuracy and completeness of the information contained in this document.

How are high performers succeeding in the KCC Model?

High performers in the KCC Model are succeeding by increasing optimal starts, raising quality scores, and generating sustained shared savings at scale. Publicly available CMS data shows the Model is generating strong results for the program’s key quality measure: increasing optimal starts, which is defined as receiving a preemptive transplant or starting dialysis without a central venous catheter.

As the Model matures, it is also demonstrating the potential of value-based care to bend the cost curve on kidney care management in the United States.

As one of the largest participants in the Comprehensive Kidney Care Contracting (CKCC) program option, Interwell Health has consistently delivered strong quality scores and sustained shared savings growth at scale. In the first three years of the KCC Model, Interwell reported $273 million in shared savings and achieved an average quality score of 88 percent—9 points higher than non-Interwell participants—and the largest share of the three-year high performer pool (44%).

Interwell Health Kidney Contracting Entities (KCEs) performance in the KCC Model

Since the program’s inception, Interwell Kidney Contracting Entities (KCEs) have consistently delivered measurable improvements in quality metrics including higher rates of optimal dialysis starts, improved Patient Activation Measure (PAM) scores, and increased access to transplant and home-based therapies. These results indicate that success in the KCC Model is possible—but it requires disciplined strategies, careful use of data and analytics, and effective implementation.

Five key strategies to succeed in the KCC Model

Based on the experience of top providers and extensive data analysis, Interwell identified five strategies associated with quality performance and cost savings in value-based kidney care. The five strategies to succeed in the KCC Model are: setting optimal starts as the gold standard, prioritizing care coordination, leveraging data for continuous improvement, standardizing post-discharge follow-ups, and reducing missed appointments.

1. Set optimal starts as the gold standard

Optimal starts prevent patients from “crashing” into dialysis—a scenario associated with higher mortality and costs. In the first three years of the CKCC program, Eastern Nephrology Associates in North Carolina achieved an optimal start rate nearly three times higher than the national average¹ by focusing on care coordination and data-driven performance improvement.

Dr. Carney Taylor, former co-president of Eastern Nephrology, says it’s also important to set a high bar and rally the practice around achieving shared goals. In his role as chief medical officer at Interwell Health, Dr. Taylor works with nephrology practices across the country to help them succeed on their own value-based care journeys.

As part of that work, he helps nephrologists and practice administrators implement best practices for increasing optimal starts, such as:

• Standardize CKD care pathways based on patient data and treatment algorithms.
• Provide comprehensive kidney disease education covering all treatment modalities—including transplant, home dialysis, in-center dialysis, and active medical management.
• Establish a preemptive vascular access placement process to ensure timely availability of AV fistulas or grafts.

2. Prioritize care coordination

Seamless coordination among physicians, advanced care practitioners (APPs), nurses, and other care team members is essential to navigating the complexities of nephrology patients’ care. Embedding renal care coordinators (RCCs) into workflows helps practices ensure that patients experience smooth transitions and actively engage in their health management plans.

“We decided to bring in a RCC when we first partnered with Interwell in the current government value-based kidney care program,” said Dr. William McElhaugh, a nephrologist at Kidney Care Specialists. “To be honest, without an RCC I don’t know how this program would work, because the RCCs do so much in terms of increasing optimal starts and engaging family members.”

Kidney Care Specialists is part of the Interwell Philadelphia KCE, one of only five KCEs to earn a perfect score in the 2024 program year.

Related reading: How Renal Care Coordinators Support Value-Based Kidney Care

3. Leverage data for continuous improvement

Using data analytics in nephrology value-based care helps practices identify areas for improvement, measure progress, and forecast trends. A dedicated electronic health record (EHR) is a critical tool for accessing real-time data and making it actionable. For instance, the nephrology specific EHR Interwell Acumen™ supports nephrologists in value-based care models by identifying at-risk patients and streamlining workflows.

“Having reliable data to share with our team in all areas of the practice and understanding our participation in the KCC program shines a spotlight on our patient care goals and ignites awareness practice-wide,” said Jennifer Huneycutt, executive director of Metrolina Nephrology Associates in North Carolina.

Related reading: How One Nephrology Practice Earned a Perfect Total Quality Score in the Government Value-Based Kidney Care Choices Model

4. Standardize post-discharge follow-ups

The KCC Model also measures practices on their 30-day readmission rate². A critical step to reducing CKD patient readmissions involves connecting patients with a nephrologist post-discharge. Interwell analysis revealed patients who visit a nephrologist within 14 days of discharge are almost 25 percent less likely to be readmitted.

Practices can take proactive steps to reduce readmissions such as:

• Establish a workflow for timely notifications of discharge.
• Contact patients within two business days of leaving the hospital.
• Ensure rounding providers are aware of transitional care management (TCM) opportunities.
• Use TCM templates (available in Epic® and Interwell Acumen Rounder™).

5. Make a plan to reduce missed appointments

Missed appointments disrupt care delivery, reduce patient education opportunities, increase the risk of emergency visits and hospitalizations, and can lead to higher total costs of care. Addressing appointment adherence is critical to patient activation and long-term outcomes.

Practices can actively track and address appointment adherence by:

• Clearly documenting reasons for missed visits.
• Introducing interventions such as patient reminders and flexible scheduling.
• Partnering with a value-based care organization to identify and address barriers to appointment adherence, including health-related social needs that may affect access to care.

The future of the KCC Model

CMS has shown a strong interest in extending the KCC Model, even as it phases out several other CMMI programs. Designed with a progressive structure, the Model has become more stringent each year to drive continuous improvement in patient outcomes and cost efficiency. Based on participants’ results, CMMI has also refined performance measures and benchmarks to enhance accountability and ensure financial sustainability. As the program progresses through 2027, its success will be pivotal in determining the future of value-based kidney care in the U.S.

The KCC Model isn’t just an experiment; it’s a roadmap for the future of value-based kidney care. Success in the KCC Model positions practices for the broader value-based care framework CMS envisions for Medicare. It also enables practices to engage successfully in value-based programs with private payers, as commercial health plans increasingly move toward value-based models. By forming strong partnerships, leveraging innovative data tools for managing chronic kidney disease, and prioritizing patient-centered care, nephrology practices have an opportunity to redefine how they deliver care and shape the future of kidney health.

Are you ready to achieve success in value-based care? Discover how Interwell Health supports nephrology practices with strategies to enhance kidney care.

References:

1. USRDS 2025 Annual Data Report: End-Stage Renal Disease Chapter 1: Incidence and Prevalence.
   https://usrds-adr.niddk.nih.gov/2025/end-stage-renal-disease/1-incidence-and-prevalence
2. Lewin Group: Kidney Care Choices (KCC) Model First Annual Evaluation Report Performance Year 2022.
   https://www.cms.gov/kcc-model-eval-ann-rpt-1-app

*Epic and Epic Connect are trademarks of Epic Systems Corporation. Acumen® has licensed an instance of Epic EHR software but is otherwise not affiliated with Epic Systems Corporation.