Episode 24:  Advancing Value Based Care with Kim Sonnen and Dr. George Hart
With more than 1,400 nephrologists from across the country as network participants, InterWell Health is a physician led organization that brings together the expertise of a diverse and preeminent group of nephrology practices to advance value based models of care. Kim Sonnen, President, and Dr. George Hart, co-Chief Medical Officer, join Field Notes to examine InterWell Health’s promising ability to improve patient outcomes while lowering costs.

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Brad Puffer: Welcome, everyone, to this episode of Field Notes. I'm Brad Puffer on the Medical Office Communications Team at Fresenius Medical Care North America and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. When it comes to people living with chronic kidney disease and kidney failure, the goal to improve patient outcomes while lowering costs can be especially challenging. Fresenius Medical Care North America is committed to this mission and has a number of initiatives in place to not only improve care for patients with kidney failure, but to actually try and slow the progression of kidney disease. The creation of InterWell Health at the end of 2019 has been key to that effort. And its membership has grown considerably. There are now more than 1,400 nephrologists from across the country who are network participants. This new organization is physician-led, with physician investors and members, while also supported by Fresenius Medical Care North America. It has brought together the expertise of a diverse and preeminent group of nephrology practices to advance value based models of care, which have the goal to drive better clinical outcomes for our patients, while also lowering overall health care costs. Joining us to discuss how InterWell is advancing value based care is Kim Sonnen, President of InterWell Health and Dr. George Hart, Co-Chief Medical Officer for InterWell Health and President of Metrolina Nephrology Associates. Kim, Dr. Hart, welcome to Field Notes.

Kim Sonnen: Thank you, Brad, for having us today.

Dr. George Hart: Glad to be here.        

Brad Puffer: So Kim, maybe we could start with you. I'm wondering if you can give us a brief rundown of what InterWell Health is all about, and how it operates. It's certainly growing fast.

Kim Sonnen: Yes, we've experienced incredible growth since inception. InterWell Health is a national physician-centric renal organization dedicated to delivering value and driving innovation for renal patients, providers, and payers. Our competitive strength is our physician ownership, leadership, and alignment that places the nephrologist at the forefront of our success in improving clinical outcomes, enhancing patient experiences, and lowering the cost of care.

Brad Puffer: Well, Kim, I was wondering if you can give us a little more into the background of how InterWell Health came about. What is that background story?

Kim Sonnen: InterWell Health was founded in 2019 by 16 nephrology practices and Fresenius Medical Care with the singular purpose of accelerating the transition to value based care. If you think back to 2019, there was a lot of activity driving value based care initiatives. We have the 21st Century Cures Act, the Executive Order on Advancing American Kidney Health, and the CMS announcement of the new CMMI models of care. So as we looked at these various companies and models, what was clearly missing in our view is a renal value based care company that put the physician, the nephrologist, at the forefront of the shift from volume to value. This is really what distinguishes us from all others.

Brad Puffer: Well, Dr. Hart, as a practicing nephrologist, what was your initial opinion of this physician-led concept that InterWell Health's proposed. And why were you excited to become its Co-Chief Medical Officer?

Dr. George Hart: From the beginning, the leadership team at Metrolina Nephrology was intrigued and excited to be a part of something like InterWell. Kim captured the environment that was going on back in 2019. And we believe that value based care is the direction that health care has to pivot toward if we're going to have any hope of addressing some of the quality concerns and cost overruns that seem to plague our health care system today. To have an opportunity to be on that cutting edge was just an opportunity that we didn't think we could pass on. As for me being asked to join Dr. Ketchersid as Co-Chief Medical Officer, I'd been a nephrologist for 25 years and been in leadership roles for 15 years, so I thought it was really a perfect time in my career to try and bring a different perspective and compliment the skill sets.

Brad Puffer: And Dr. Hart, why should nephrologist consider joining? And really, why is this value based model of care so important right now?

Dr. George Hart: As we've learned, nephrologists are really hungry for this kind of an opportunity to be a part of transforming health care. InterWell's providing that opportunity. It's unique. And it's really unlike any other offering that's available to nephrologists out there today. Why should other nephrologists want to join us? All nephrologist want to deliver top-notch care and associate with and have camaraderie with high performing, innovative peers. If you look at InterWell, in our cross section of nephrology practices across the country, I think we epitomize that sort of ideal. It's very exciting. And as you mentioned, we're kind of growing by leaps and bounds over the past 18 months.

Dr. George Hart: Kim, you kind of hinted at some of the changes that were happening in 2019. And Fresenius Medical Care North America, has now announced a number of value based care agreements with private insurers just over the last year. And some include efforts even to slow the progression of kidney disease, helping keep more patients off dialysis. And that might be surprising to hear coming from a dialysis company. But how did these efforts help our patients and the health care system?

Kim Sonnen: The partnership with InterWell Health is a natural evolution as we shift from fee-for-service to value based care. It allows us to focus on the entire continuum of care. We're able to move upstream for early identification of CKD patients, that are at risk for developing CKD. With this early identification, we have the opportunity to potentially stop or slow the progression of the disease state.

For those patients that continue to advance in their disease, we provide education and support for the full spectrum of modality selections-- the transplant, preemptive transplant, home dialysis, therapies, and in-center dialysis with optimal start.

Brad Pufer: Dr. Hart, what will be the key then to these earlier interventions? Why is partnering with insurance companies or the government so critical to identifying people with CKD earlier so they can actually be treated effectively?

Dr. George Hart: The ESRD patients comprise about 1% of the Medicare population, but about 7% of the Medicare spent. And with the migration into Medicare Advantage because of the Cures Act, private payers are now seeing a larger impact. So both have a vested interest in trying to solve this problem. And we want to be part of the solution. We want to partner together so that decisions that are being made or appropriate from a clinical standpoint. As all of this expands to include late stage CKD, stages four and five, the cost and the societal impact are just increasing tremendously. We're still on the leading edge of the baby boomers, so we really have another 10 to 15, maybe 20 years to run through this expanding aging population. There are focuses that we're going to have now on trying really to better manage transitions of care. So we want to identify the unrecognized CKD patients, because it's proven that if nephrologists are involved, outcomes are better and costs are lower. We want to manage the transitions that come along with hospitalizations. We know those are vulnerable times in the journey of patients. We want to do comprehensive advanced care planning and determine what's the best treatment course for an individual patient. So we want to focus on-- if patients are going to need to start some sort of renal replacement therapy, we want to have them have access to early transplantation opportunities. We want to focus on optimal starts, which we define as starting dialysis at home or starting without one of these indwelling catheters that are associated with increased infection risks and morbidity early on.

Brad Puffer: And these are great goals, Dr. Hart. So what are some of the actual initiatives that InterWell Health is able to lead? And how does being part of this group help you achieve those goals?

Dr. George Hart: So part of what we're doing, is we're creating incentives for physicians to carry out some of the tasks that we know make a difference, seeing patients soon after a hospitalization where you can coordinate medications, changes in weights, and different treatment procedures, is going to be really important in keeping patients out of the hospital. We're working on putting together educational programs that have medication lists to identify medications that are at high risk of causing worsening kidney failure, because the last thing you want is acute kidney injury superimposed upon chronic kidney disease. When that happens, patients end up back in the hospital. They end up with accelerated unrecognized progression of their renal failure. And they're more likely to crash into dialysis, which leads to all kinds of bad outcomes.

At the same time, we're creating a data network, where we're going to be able to, down the road, be able to provide feedback back to physicians in the practices on how they're doing, not only in absolute terms, but in comparison to their peers. And we think that sort of feedback will be important long term.

Brad Puffer: Kim, I was curious then, what is the investment from Fresenius Medical Care mean? And what does Fresenius bring to the table as part of this partnership?

Kim Sonnen: I would say unparalleled experience, scale, and success. They really are the leader in renal value based care. They have a proven track record with the ESCOs and commercial partnerships. Fresenius health partners, integrated clinical team, analytics, care coordinators, educators, and patient engagement programs are just some of the benefits that they bring to this partnership.

Brad Puffer: Well, Dr. Hart, Kim briefly mentioned ESCOs, one of the early, innovative, value based care agreements coming out of the government, that happened over the last several years. And now there are many new voluntary government model that are coming out from the Center for Medicare and Medicaid Innovation, really aimed at physicians. And those are set, my understanding is, to launch next year. Can InterWell Health and health physicians be successful in those new models? And why are those efforts so important?

Dr. George Hart: Voluntary models are important for several reasons. We now bring a wealth of experience from the ESCO models into this new model. So nephrologists are more sophisticated, Fresenius is more sophisticated, and this opportunity to take what we've learned over the past five years and now apply it to a new model is quite exciting. The ESCOs were focused only on dialysis patients. Now we've expanded this population and our target to include advanced CKD patients as well as patients who receive a kidney transplant during the life of the program. We're excited about all this. And again, I think we have a greater opportunity now to have an impact, than we would have four or five years ago, as we were all kind of learning what this transition into value based care would mean.

Brad Puffer: Well, Kim, do you think these new models of care that we've been discussing, this push to value based care, really is the future of health care and kidney care in this country?

Kim Sonnen: This is a complex chronic condition. Patients struggle in a fee-for-service environment without the support and coordination that's offered through these value based models of care. So yes, it is absolutely the right thing for our patients. And it's right for our industry.

Brad Puffer: And Dr. Hart, I just want to end with you. Thinking about the future of InterWell Health and its growth, it seems like there's room for more nephrologist to become part of this organization. What is your final pitch to those nephrologists out there that might be listening to learning more about InterWell Health for the first time?

Dr. George Hart: I'd just sum it up by saying that we're excited to add like-minded nephrologist and nephrology practices that are really interested in making this pivot away from fee-for-service toward value based care, which really is the opportunity that we have in the future to be freed up to do what we as physicians have been trained to do and then also to pursue care models where you can tackle some of these limitations that are imposed upon us because some of the social determinants of health.

So, if you're looking to be a part of not just a local or regional network, but a true national network of preeminent nephrologists, come join us. We're happy to have you part of what we think is going to be a very exciting journey over the next five to 10 years.

Brad Puffer: Well, Dr. Hart, Kim, we certainly will be watching closely to see what that journey looks like over the next five years. And I wish you both much success. This has been a great conversation. Thanks for joining us.

Dr. George Hart: Thank you.

Kim Sonnen: Thank you so much, Brad. We really appreciate you having us.

Brad Puffer: Yeah, thank you, both. I really think this is the new frontier of innovative health care. And to our audience, thank you for joining us. Please know that your feedback is always welcome. If you have any comments on today's episodes, topics of interest to you, or speakers you'd like to hear from, let us know by clicking the Feedback link featured on the Field Notes website on fmcna.com.

Don't forget, you can find Field Notes on the Apple Store, or Google Podcasts, or right here at fmcna.com, where you can also find our annual medical report, and other featured articles. We hope you'll come back and join us as we have many more topics that we'll be discussing in the weeks ahead. Until next time, I'm Brad Puffer. And you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.