Interwell Health was formed in 2022 by the merger of Fresenius Health Partners, the value-based care division of Fresenius Medical Care North America, with Cricket Health and Interwell Health, a network of nephrologists. Its network has since grown to include more than 1,700 nephrologists in 135 practices. Healthcare Innovation recently sat down to talk with George Hart, M.D., Interwell’s chief medical officer, and Carney Taylor, M.D., M.B.A., who leads Eastern Nephrology Associates, a practice with 32 nephrologists in eastern North Carolina and has experience transitioning his practice to value-based care.
Healthcare Innovation: Dr. Hart, we have followed Interwell’s progress and partnerships, such as the joint venture with primary care provider company Oak Street. Are there some significant developments in the company's growth in the last year that you'd want to talk about?
Hart: We’ve had an exciting year. The private payer sector is very interested in continuing to cultivate a relationship with us as it relates to both commercial populations and Medicare Advantage populations. We've expanded some of our pre-existing agreements and are continuing to talk with both national and regional players. We've expanded our footprint down into Puerto Rico. We're working with two large payers down there. Who we partner with is changing. We know that we need to figure out not just how to work with nephrologists, but also work with primary care, work with surgeons. So I think we're putting a toe in the water, so to speak, in those arenas, which we think is going to bear fruit and teach us how to better be prepared to go further upstream in the earlier stages of CKD.
HCI: Could you talk about the Oakwell joint venture with Oak Street?
Hart: It is in the early stages. We are working with Oak Street in select markets across the country. The idea is: let's take advantage of what primary care can bring for dialysis patients. We all know, and Dr. Taylor can speak to this as well, that dialysis patients don't really want to go to a primary care appointment. They don't want to go see an endocrinologist, because they spend so much time already in a dialysis unit. So if we can bring the care for those patients to the dialysis unit, we think that we can help manage better the co-morbidities, whether it be behavioral health or better dietary care, and create more seamless communication between primary care and nephrologist and bring that care to the patient.
HCI: Could you talk about Interwell’s work on CMS’ Kidney Care Choices alternative payment model? Can you tell yet whether the company is being successful in reaching its goals in that model?
Hart: There are limitations on what we can talk about until things become public. I think we are seeing successes in our ability to move the needle on some of the quality measures, and I think we've seen that needle move across the board. Dr. Taylor can speak to this as well because his practice probably is the most successful of any practice in the Interwell network regarding optimal starts.
HCI: What does that term “optimal start” refer to?
Taylor: An optimal start is when a patient transitions from CKD [chronic kidney disease] care into end-stage kidney disease with either a preemptive kidney transplant, meaning they never saw the dialysis unit, or they go on dialysis, either in center or at home with something other than a central tunnel dialysis catheter. That requires a lot of relationship-building with the patient and coordination of care during that transitional phase from CKD to end-stage kidney disease. So it's clearly linked to outcomes of patients if you start sub-optimally, right? You’re more likely to be hospitalized, your mortality rates are higher, your cost of care is higher. Being able to have a controlled transition into that environment is critical. We're measured by optimal starts in the CKCC [Comprehensive Kidney Care Contracting] model.
HCI: Does some of this work requires moving upstream and getting to patients earlier in the process and maybe working with other providers more closely than you might have in the past?
Taylor: Specific to the optimal start, I think you're definitely moving upstream in terms of dialysis education. You're trying to educate people about their disease and about the things that are going to come to bear earlier so that they have control over and can participate in the decision-making. There's a lot of emphasis on kidney disease education earlier and earlier. But there are opportunities to look way upstream beyond that to see how we can slow progression of kidney disease altogether.
Hart: In the CKCC models, the attribution of patients starts at stage four, so that's where we're currently leaning in with patients. But one of the advantages in these value-based care models is that we have an ability to invest in things like education, care navigation, and starting those conversations earlier in the disease process, where you have the time to deal with adherence issues. We now have the ability to follow up with these patients, and help them get from point A to point B and make sure that they don't miss appointments, make sure they have a ride. So the chance of failure is minimized versus what it would be in a fee-for-service model.
HCI: Does that involve hiring more people in a care coordination role that you wouldn't have had before?
Hart: In many markets and many practices, we embed nurses in the practice and what we call a renal care coordinator.
Taylor: We have a combination of two things that Interwell offers. One is that there are Interwell, employees who are care coordinators who work within my practice, and the nice thing is we can work seamlessly with them. A lot of my employees don't even know that they're not our employees. There is just a great strategic relationship. In addition to that, we have support care coordinators who are employees in my practice, who are adding to that overall care coordination so it's, it's an aggregate of resources. Being that connected really allows us to understand things that are going to happen before they happen or to guide the patient in the right direction for their outcomes.
HCI: Dr. Taylor, could you describe the value of being part of the Interwell network to a practice like yours?
Taylor: When you think about a kidney failure patient, whether it's stage four or five CKD or ESRD, they're the sickest of the sick, right? Their diseases are complex. They usually require the participation not only from the nephrologist, but also from the cardiologist, the endocrinologist, the primary care doctor. It's a very complicated web of healthcare and it's often fragmented, and our patients struggle to navigate through the system.
If you bring in resources from a value-based care company, it could potentially have the unintended potential consequence of further fragmenting care. But in the relationship that we have with Interwell, they are strategically aligned and embedded in us, so we're able to funnel the resources through us in ways that make more sense to our patients. It just seals up that relationship. That's one way we look at it from a practice perspective.
The other way is that when when we sat down as a group in 2019, at the beginning of the CKCC model, and had a conversation. We said that we believe in value-based care because our patients are going to get better outcomes, but we don't know how to do it yet. We can't afford to do it. We need a good partner to do it. But we also want to make sure that what we build helps not only the percentage of people who are in attributed models today, but helps the entire population of people we take care of. That requires practice transformation from the inside out. I mean, every aspect of our practices had to transform. To do that, we had to be part owner of the process. That's why we feel heavily invested in Interwell and are so symbiotically dependent on them. But it's a real partnership.
HCI: There was just an announcement about eight new practices and more than 450 providers becoming users of the company’s Acumen Epic Connect platform, which is a customized version of Epic for nephrology, in the past year. Could you talk about the significance of that? Dr. Taylor, does your practice use Acumen?
Taylor: Yes, we have been on Acumen since 2022. We want assistance at the point of care when we're taking care of patients. The EMR is always a part of it. Having an EMR that is owned by your value-based care partner is great, and it’s rapidly evolving. It's a constant conversation. But Acumen has become just part of the fabric of how we deliver care now, and it's helping us to figure out how to do it in a value-based care world.
HCI: Does it also help to have the Interwell practices on the same EHR in order to do the value-based care quality reporting and to do data analytics across practices?
Hart: About two-thirds of the Interwell network members are on Acumen. The attractiveness of Acumen is being recognized by practices and they're willing to take on the expense that comes with making that transition because they see the value. But to your question, yes, it does help to have that volume and be able to speak one language and create one solution for two-thirds or three-quarters of your network. That simplifies things dramatically for us. It also allows us to create generic reporting mechanisms that we can then tailor for a practice. They get their data back, which can then be pooled and compared with de-identified data, and you can see how you're doing compared to your peers. That's great.
HCI: Interwell has been growing and going through a lot of changes. Anything you are looking forward to in 2024?
Hart: I think we're really glad to be through a merger for the company, and be able to settled in and really operationalize. We're excited about strategies that we're developing now with some of our risk stratification, looking at how we identify patients who are at risk to be in the hospital, those who are at risk for progression. We need that to be able to work with primary care and go further upstream so that we can tailor strategies and be successful.
