Innovator Awards Winning Team: Metrolina Nephrology Associates
Even as care management continues to evolve forward in the primary care sphere, major advances are being made in specialty care management. And the pioneers in care management in medical specialty areas are forging new paths and sparking interest across the U.S. healthcare system—and for good reason.
One of the organizations making waves is Metrolina Nephrology Associates in Charlotte, North Carolina. The group practice, with 41 physicians and 42 advanced-practice providers (APPs: nurse practitioners and physician assistants), and with a total staff of 250, spread out across eight practice locations, jumped on the bandwagon when the Centers for Medicare and Medicaid Services (CMS) premiered the Kidney Care Choices (KCC) model in 2019. That model, as CMS explained on its website, “builds upon the Comprehensive End Stage Renal Disease (ESRD) Care (CEC) Model structure – in which dialysis facilities, nephrologists, and other health care providers form ESRD-focused accountable care organizations to manage care for beneficiaries with ESRD – by adding strong financial incentives for health care providers to manage the care for Medicare beneficiaries with chronic kidney disease (CKD) stages 4 and 5 and ESRD, to delay the onset of dialysis and to incentivize kidney transplantation.”
The KCC mode brought groups of nephrologists together with other kidney care providers, “to take responsibility for patients who have late-stage chronic kidney disease, End-Stage Renal Disease (ESRD), or a kidney transplant. They offer coordinated and seamless care (including dialysis, transplant, and if appropriate, end-of-life care). Additionally, model participants provide education to patients to help empower them to be more active in their care. Patients receive needed services while retaining the freedom to choose providers.”
In March, CMS announced that it was ending the model as of the end of 2025; but the leaders at Metrolina Nephrology Associates are moving forward with incorporating the model’s principles into its care management approach. And, even before joining the KCC Model, Metrolina’s leaders realized that they needed additional patient management, administrative, and quality measurement support so their team could continue to focus on delivering high-quality patient care, and decided to form the Charlotte Kidney Contracting Entity (KCE) in partnership with Interwell Health, the Waltham, Massachusetts-based kidney care management company that was able to offer the Metrolina team the resources to enable success in the KCC model, including an interdisciplinary care team, patient education, care coordination, and advanced predictive analytics and modeling to drive continuous quality improvement.
Together, Metrolina and Interwell worked to build a care team and workstreams that helped close gaps in care and improve key quality measures necessary to achieve strong results. They focused on three core strategies:
Ø Leveraging Data-Driven Insights: Using predictive analytics and real-time performance tracking, Interwell worked with Metrolina to identify at-risk patients and tailor interventions to improve outcomes. Having robust performance data enabled Metrolina to engage key stakeholders, including board members and physician group leaders.
Ø Expanding Care Coordination: With Interwell Health’s support, Metrolina integrated interdisciplinary care teams—including nurse care managers, dietitians, and social workers—to provide more holistic, patient-centered care.
Ø Improving Key Quality Measures: Interwell concentrated on enhancing critical metrics such as optimal dialysis starts, depression screening, and patient activation, ensuring that Metrolina met and exceeded KCC program requirements.
While many healthcare organizations invest in individual tools—engagement platforms, data analytics, or EHRs—Interwell worked with Metrolina to combine all these elements with the right patient care team to create a seamless, high-performing system. They recognized that it’s not just about having the right technology or incentives but about building the connective tissue that enables everything to work in concert.
The results have been outstanding. In October 2024, CMS released results from the first year of the KCC program. Metrolina emerged as a top national performer – with a Perfect 100-percent Total Quality Score, demonstrating excellence across all tracked metrics.
Here’s a sampling of other results:
Ø Optimal Starts: Among the highest in the nation (69.41%), ensuring patients initiated dialysis in a planned and less disruptive manner.
Ø High Patient Activation (60.81%) & Depression Screening Rates (77.94%): Indicating robust patient engagement and comprehensive psychosocial care.
Ø Notable Cost Savings: Early indications show that Metrolina’s proactive approach helped avoid high-cost hospitalizations and complications resulting in $8.5m in shared savings for 2022.
Beyond the statistics, these results translate to real patient benefits—earlier interventions, fewer hospital visits, and better patient outcomes.
All of those results, and the strong strategies behind them, led the editors of Healthcare Innovation to select the leaders at Metrolina Nephrology Associates to be one of the three winning teams in this year’s Healthcare Innovation Innovator Awards Program.
And, per all that, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed several senior leaders at Metrolina, to get a fuller picture of their accomplishments. Those present in the virtual interview were executive director Jennifer Huneycutt; nephrologist and partner Carl Fisher, M.D.; nephrologist and medical director of kidney care Thomas Smarz, M.D.; Leah Smith, R.N., N.P., director of advanced practice providers; and Jan Fincher, director of value-based care. Below are excerpts from that group interview.
Why did you all decide to participate in and implement the Kidney Care Model?
Jennifer Huneycutt: We had try to be innovative in this space before it was even a space. Leah and Dr. Fisher had started in 2010. In fact, in 2015, the ESCO model (End-Stage Renal Disease Care Organization), the predecessor of the KCC, emerged; that model ended in the first quarter of 2021. And this model started in 2022. So this is the second iteration of the model; and we hope there will be another one. So in light of what we’ve done, we’ve learned a lot of lessons along the way; the model keeps evolving to be even more supportive of our goals; this model aligned with how we see care. And we just saw a huge opportunity o improve outcomes and lower costs. We want to be a part of the evolution of the healthcare payment system and how it works. We also recognized that there needs to be support built out into the infrastructure. In fact, the further along we get, the more support we need, and this gives that.
Thomas Smarz, M.D.: Just generally stated, individually, we’re blessed with a lot of providers who are great individual clinicians and do a great job for their patients on a one-on-one basis. But in a practice this size, there has to be a higher-level view. And we started years ago, but were limited by the resources we had and the tools in the toolbox, to determine what our outcomes were. Our EMR was less powerful; and we didn’t really even have a data analytics team. And the ability to see things through a wider lens helps us reduce hospitalizations, reduce cost, and improve outcomes. We’re able to think and act more proactively. And analytics is a big part of it. Years ago, we had talked about databasing things we were interested in; but we had no real database, and our EMR didn’t allow us to query. Fortunately, we’ve moved well beyond that, in the ability to understand our outcomes.
Carl Fisher, M.D.: One thing to keep in mind is that we are uniquely positioned for what we hope is a successful population health management approach. This is stages four and five CKD and dialysis patients; these are the sickest people we see among thousands. So we knew if we could create a population health management platform with Leah’s help, and could manage patients better—we’re essentially a primary care clinic for very sick people. We see dialysis patients four times a month, and for stages four and five patients, we see them quarterly. And we’re now starting to see that you can have better outcomes and save money, the more often you touch them. Chronic care management can mean touching them via text messages.
Leah Smith, R.N., N.P.: The word “advanced practice providers” encompasses nurse practitioners and physician assistants. And we were early on in focusing on advanced practice providers in nephrology; we have 42 APPs, the largest in the country, alongside 41 nephrologists. The nephrologists really jumped into that co-management model. And what I’ve seen as a NP/APP, as we’ve jumped into the first VBC model and now the second one, we’ve seen a shift in how we approach patient management. We’ve always focused on slowing the progression of disease. My watch phrase is, any day not on dialysis, is a good day. And so we’re focused on the metrics that help slow the disease, whether working on their diabetes or focusing on the right medications to slow the progression of disease. And as we’ve moved into VBC, as Dr. Fisher explained, we become a care coordinator for patients; this model serves us well in that way, and has the APPs function up to the top of our scope of practice. And the nephrologists have supported that.
Can you speak to the cultural change that’s taken place in recent decades around the participation of advanced practice providers in managing care, and the emergence of multidisciplinary approaches that bring together physicians and APPs as a real team?
Smith: It’s been a trajectory. When I began in 2001, I was the third APP hired. And our physician leadership said, hey, we should use this role more and expand it. And for cost-benefit ratio—we’re a third of their cost yet can still add to the bottom line. So fortunately from the beginning, we had nephrologist support. I’m not saying a few nephrologists weren’t unaligned at first, but as soon as we presented good data around our impact, the support continued to build, to the point that—and the way we feel as the APP team—we value the physicians’ trust. They do feed into us and we feed into the team as well. We’re seeing this start to happen around the country—we’re seeing more APPs being optimally utilized; but we’re definitely on the forefront of that. Trust is the key.
Fisher: It hasn’t always been an easy sell. We certainly had folks we needed to do a bit more convincing on. But now, with the sheer volume of patients we have, it needs to be co-managed. And we link individual APPs to individual nephrologists, that helps. And we have protocol-based treatment algorithms. But the real sell is that the patients aren’t pushing back. That’s because of the APPs’ quality.
Smarz: I would say that Carl and I are of the age, we’re the physicians in that transitional age. Some of the more gray-haired folks might have been more resistant. And I’m married to a nurse practitioner, so my acceptance was compulsory—that’s a joke! But it started with carefully defined roles and supervision. And some of our APPs are really, with their clinical skills, almost practicing at an MD level. It’s been a great team approach.
Huneycutt: And, back to your original question about our population and why VBC, it’s important to know that end-stage renal disease patients represent 1 percent of the Medicare population, but closer to 8-9 percent of Medicare spend, so that’s a big deal. And int terms of the physician-to-APP concept, the culture of the practice here is that the physician culture invests in their team, whether a clinician or an administrative-type person like myself, and they support all of us to spread our wings, and let us do the things we’re capable of doing, and they trust us. And that’s a big part of the culture here. Also, per the APPs, over the years of growing the program, Leah has developed a training program called Ready For Rounds, we’ve trained over 300 APPs nationally, and we invest a lot into the training. We’re the national standard. Interactivenephrology.com
Jan, what’s your gloss on all of this?
Jan Fincher: So much of the framework for value-based care was already in place here, so that by the time I got here—I just had to figure out operationally how I would implement the requirements for administering surveys, and such. But the concept was already there, as was the support. I didn’t have to do much to change that culture. Operationally, the people here, the staff here, all bought into the same thing. We’re all trying to slow the progression of chronic kidney disease, and if a patient does transition to an advanced stage, we need to manage their care optimally. And these value-based contracts don’t include all patients. We were used to doing things the same way for all patients. We’ve had to change things a bit in terms of how you do things for the patient in the program, but this has kind of forced us to have a prospective approach than a reactive one, with patients. And our chronic care management program definitely supports that concept, and that ensures continual contact with patients. They need that contact, if we’re trying to slow progression and reduce total of care, you do that by staying in contact with your patients.
How are you using the data?
Huneycutt: Our use of data has evolved. Initially, we couldn’t mine data in a successful way. After the structured CKD program was created, we started pulling data from our practice management system/scheduling data/demographics, with clinical data from the EMR. And the database was built to capture the milestones we were trying to capture. Has the patient yet received any education about their kidney disease? Late-stage: have they been referred to a surgeon, has that surgery occurred, has it been successful/ So we’ve built workflows and power business intelligence, to look at the data from the physician level, location, stage of kidney disease; we could slice and dice it in many ways. And the cool thing about it was that by building it ourselves, it informed the workflow. And that’s so important in terms of mining the data successfully. That’s one of the first places where we began to have focused workflows. We’re large for a nephrology practice. And that piece informed our workflows, and vice-versa.
And from there, we implemented that and built it in 2017. It also helps us with visit frequency and losing patients on follow-up. It’s a kind of pull approach, we have to reach out to them. And this past year, we sunsetted that tool as we’ve moved into Acumen Epic; it’s an instance of Epic opened by Interwell, our partner in VBC. And it’s customized for only nephrology. And they put in the infrastructure and investment into tailoring it into VBC uses as well. We just went And I was data queen; I built that.
When you think about data as physicians, what do you think about?
Smarz: I tend to think clinically. Early on, you attend morbidity and mortality conferences, where physicians will present cases where things went wrong. You try to get to the root cause, but it’s a one-case-at-a-time approach. The data analytics allows us to do that on a much broader scale. One of the things we look at is, optimal commencement of dialysis. We try to capture that analytically: we don’t they get dialysis at a certain point? And having the data analytics and honestly, the correct data, allows you to get to, where did we fail as an organization? Where are the obstacles, the crevices? Without that kind of information, you can’t get to the right outcomes at scale.
Is it that patients are started too late on dialysis?
Smarz: Not so much the timing, but the question of whether they’re adequately prepared or not. We don’t want them to “crash” into dialysis, where there’s been no care management in place. So there’s a process in place. Some of that includes referring them for transplant, and trying to proactively refer them for a transplant. So being able to optimize the processes, is important.
Fisher: As Jennifer said, we have our roles. I don’t consider myself a data guru, but my vision for leading the practice involves—we have this chronic care platform, where Jan and patients can communicate with patients. Simple things like, have you filled your blood pressure medication? Things like that. And do those touchpoints, which could be quite frequent for some patients, lead to fewer hospitalizations and lower utilization and cost? I’d like to be able to explain to my partners that we know how we’ve improved things.
Jennifer: That’s one of the hard things. We don’t necessarily know the impact of a single intervention. And you can retrospectively look at differential outcomes. But is it causation or correlation?
Have there been any challenges in developing or optimizing the model?
Fisher: It takes a heavy lift to create this, and if you’re a five-partner practice in the middle of Illinois or something, you might not have the funds. But it’s not a light lift to create a VB program.
Fincher: It definitely requires resources: we have 250 employees and eight practices, and ten individuals focused exclusively on the value-based care program. To me, a challenge is educating your staff. We’re four years in to our CKCC patients; and I’m still educating staff on helping them to identify who’s in the VBC program. I feel very blessed that I walked into a practice that was already value-based care-minded. It’s
Huneycutt: Only 6-7 percent of our patients are covered by the value-based care program. Also, nephrologists, while their activities are similar to PCPs, they’re not in the office all day; they spend their time in the hospitals, on dialysis care units. Some may only spend a small number of hours a month in the office. And some of the interventions are honestly too expensive to pay for without the support of a value-based care model to pay for them. So you’re mostly living in a FFS world, and trying to play a balancing game.
Smith: And the education is not a one-time thing. Anytime a new innovation comes out, we need to share that. It means continuing to put this in front fo the clinicians, reminding them why we’re doing it, and the data. But for them to see their impact is very important. I think we did that very well last year; we were really able to inspire interest leading into 2025. Abd the APPs do three of the four dialysis rounds with patients. We’ve been focusing on things like encompassing advanced-care planning, transition care management, optimization of charting, with the APPs, in our program. That’s been a key as well.
Fincher: I agree. A lot of the operational workflows, they funnel through the APPs well before they go through the providers.
What’s ahead in the near future?
Fincher: I think that the fee-for-service world will begin to phase out, and you’ll have more and more of your patients in these value-based contracts. And a lot of times, the roles continually change. And so there’s going to be a more and more of those types of adjustments; and just having the bandwidth to manage all the programs; it’s not as though one value-based contract will fit all.
Huneycutt: We’re hoping to expand more into commercial and MA contracts. We want that 6-7 percent to grow and expand; it will help us manage care better. Right now, everything is stage 4 or 5 or patients already in end stage disease. But we’re finalizing a contract that will go into stage 3; slowing progression is the key. And as we started in VBC, we put VBC in a department; but value-based care strategies and concepts need to permeate the entire practice. I could see us—some of that centralized work needs to go out into the practices. And having those care coordinators out at the point of care, would go a long way to integrating the staff. And we hope to continue to talk about what’s working and not working; we’re a big sharer.
