How a Regional Health Plan Saved $3.6 Million and Reduced Member Hospitalizations by 30 Percent

The challenge

A regional health plan with a growing footprint across the southeast wanted to improve the quality of life for their members living with chronic and end-stage kidney disease while lowering total cost of care. They were interested in shifting from traditional fee-for-service reimbursement to a value-based model that links payment to health outcomes.

A growing burden

Chronic kidney disease (CKD) takes a major toll on patients – almost 37 million Americans are currently living with the disease. This is also an enormous economic burden for payers and healthcare systems, accounting for over $84 billion in Medicare expenditures each year.

The southeastern region where most of the health plan’s members live has one of the country’s highest rates of end-stage kidney disease (ESKD) and one of the lowest rates of kidney transplants¹. Comorbidities like diabetes and hypertension are also extremely common.

This regional prevalence, coupled with the clinical complexities associated with kidney disease, was a significant cost driver. Late-stage CKD (defined as CKD stages 4 and 5) and ESKD cost the health plan $27.9 million each year. Before our partnership, the health plan was spending $2,240 per member per month (PMPM) for individuals with late-stage CKD and $9,600 PMPM for individuals with ESKD.

Choosing the right partner

Health plan leadership knew they needed a value-based care partner to address these challenges. As they explored options, they searched for a partner that would:

• Lower medical costs
• Fully integrate in-network providers into their care management solution
• Increase quality of care for their members
• Take full total cost of care risk on all eligible members, not only members they enroll
• Generate data-driven insights
• Successfully recruit and incorporate local nephrology practices into an existing national network to improve outcomes and care coordination

The solution

Interwell Health, a value-based kidney care company, has developed a proven model that delivers better health outcomes for patients and significant financial results for payers. 

After thorough review of solutions in the market, the health plan entered into a contract with Interwell. We stood out from the competition because of our: 

• Comprehensive clinical network, anchored by the largest national network of nephrologists
• Robust data interoperability and advanced analytics
• Unparalleled experience at scale 
• Aligned economic models that guarantee quality and financial outcomes for members

The agreement included all eligible Medicare Advantage and Medicare Advantage Special Needs Plan members with either late-stage CKD or ESKD across all states where the plan operated. 

A powerful nephrology network

We worked closely with the health plan to understand the needs of its member population. We recruited and integrated six large regional practices and 47 nephrologists that were currently caring for the health plan’s members into our network, bringing our network coverage of current members to 50%. 

These affiliated practices receive the resources and tools to successfully implement value-based care workflows, and have access to technologies like Acumen, our nephrology-specific electronic health record, to improve data capture and care coordination. 

We’ve been able to create the largest national network of nephrologists because our agreements include patients covered by multiple payer partners. Our provider incentive programs are payer agnostic, which means providers treat the patient in front of them with all the resources they have, regardless of the value-based care arrangement the patient happens to be in. This patient-centric approach improves care quality and reduces cost.

Our ability to build – and leverage our existing – regional presence uniquely positioned us to engage with the health plan’s members in their nephrologist’s office, at their dialysis clinic, in their home, and everywhere in between.

Working together

Together, we tailored incentives and deployed a model that integrated into the health plan’s existing processes and structures.

1. Analyze

The first step in our partnership was putting data to smart use. Through advanced analytics, we were able to identify and engage eligible members at elevated risk for adverse outcomes like hospitalizations and rapid disease progression. These insights enabled a more proactive approach to patient care and helped our care teams provide targeted interventions, such as:

• Patient-specific follow-up
• Frequent check-ins
• Priority connection to a nephrologist  

2. Engage

As we laid our analytics foundation, we began to establish a relationship with attributed health plan members. We used an agile patient engagement marketing campaign with multiple touchpoints to drive awareness and enrollment among the health plan’s entire eligible population. Through phone calls, direct mail, and care team resources embedded across our provider network, we explained how our program works and how it could support them.

Our campaign delivered immediate results. Most members we connected with expressed interest in our program, and we saw a 60% year-over-year increase in engaged CKD members.

3. Deliver

Once members were enrolled with Interwell, they were paired with a dedicated nurse care manager and service coordinator who worked closely with their provider to help them manage all aspects of their kidney disease – from developing a personalized care plan to managing comorbidities. They also received customized education to empower them to make informed decisions about their care.

Additionally, they were connected to a multidisciplinary care team of social workers, nurses, dietitians, and pharmacists who could address their unique needs. This team could be reached anytime, anywhere via phone or an application, and could help with:

• Coordinating care for comorbidities like diabetes and high blood pressure
• Following up between appointments
• Facilitating communication between patients and nephrologists
• Arranging transportation
• Improving diet and eating habits
• Making healthy lifestyle changes
• Managing and reviewing prescriptions

Research² shows patients with late-stage CKD or ESKD are vulnerable to depression and anxiety. Our licensed social workers screened members for depression early and often to ensure they received the proper interventions – including counseling, referrals to outpatient behavioral health, and connection to community resources. This support was especially important given the strong association of depression with worse health outcomes and reduced quality of life.

Members progressing to ESKD received additional interventions, including dialysis modality education and training, and transplant coordination. This proactive involvement decreased unnecessary hospitalizations and empowered members to live a full life while on dialysis.

Payment model

We entered into a value-based payment model where Interwell delivered a guaranteed reduction to the health plan’s historical total cost of care, taking full risk on all eligible late-stage CKD and ESKD members. At the end of each year, total spending was compared with a target that reflected the guaranteed savings discount, and the difference was shared between our organizations. This is just one type of value-based payment model we offer our payer partners.

 

Member Story: A CKD Member Delays Dialysis, With Help from Interwell

Amy, an 85-year-old with late-stage CKD, fills her plate with kidney-friendly foods like legumes and vegetables. She uses fresh herbs to season her meals. And she always practices portion control.

But she wasn’t always so health conscious.

When she was first diagnosed with CKD, she would have opted for salty snacks and lots of protein. But everything changed once she connected with Interwell through her health plan.

She was immediately assigned an Interwell CKD nurse care manager who connected her with a registered dietitian. The dietitian worked closely with her to implement diet and lifestyle changes to delay dialysis.

Whenever Amy had a question, her care team provided guidance. And they proactively checked on her in between appointments.

This care model has motivated Amy to take steps to protect her health. She’s also seen meaningful clinical results: Interwell has helped Amy attend several necessary medical appointments and her last three labs over two years have shown that her eGFR levels – a key indicator of kidney function – have stabilized.

 

Member Story: Improving Care Coordination for a Recently Hospitalized ESKD Member

75-year-old Deborah has ESKD and has been on dialysis since early 2020. She had poorly controlled blood pressure and is legally blind – relying primarily on family members for support.

Interwell’s population health nursing team reviewed Deborah’s medical records and noticed that she had been recently hospitalized. They determined that she needed further assistance with care coordination.

Deborah’s assigned ESKD nurse coordinator helped her establish a relationship with a primary care physician and an ophthalmologist so she could receive regular monitoring. The nurse coordinator also educated Deborah about the importance of follow-up appointments and proactively monitoring her symptoms to avoid readmission into the hospital.

Today, Deborah can better manage the complexities of her care journey. She attends all follow-up appointments and oversees her medications independently.

Transparent results at scale

With Interwell, the health plan found a partner that shared its commitment to innovation and quality care. Our collaboration improved several key outcomes in a challenging patient population and resulted in significant cost savings. 

 

These results are clear indicators that Interwell can drive outcomes for large populations at scale. We measure our results across all eligible patients and also benchmark our data with the United States Renal Data System to allow for direct and transparent comparison. 

Reduced hospitalizations

Hospitalizations incur large costs and fragment patient care. We reduced all-cause hospitalizations among late-stage CKD members by 25%, lowering rates from a baseline of 1.06 admits per member per year (PMPY) to 0.79 admits in 2022.

We saw a similar reduction in the ESKD member population. All-cause hospitalizations were lowered by 30%, from a baseline of 1.65 admits PMPY to 1.16 admits in 2022.

Increased optimal starts

An optimal start to dialysis is defined as any attributed ESKD member who either receives a preemptive transplant or starts dialysis:

• At home (with peritoneal dialysis or home hemodialysis)
• In-center with a permanent vascular access (arteriovenous fistula or arteriovenous graft)

Our interventions resulted in an optimal start rate of 23% – representing a 27% increase since the start of our partnership.

Significant cost savings

We lowered the cost of care in both the late-stage CKD and ESKD populations by 13%. These reductions resulted in total savings of $3.6 million for the health plan.

 

Related Stories

After a Preemptive Transplant, a New Lease on Life

Mary Johnson was stunned to learn she had chronic kidney disease. After her diagnosis, she worked with Interwell Health for almost two years to delay kidney failure and avoid dialysis while she waited for a successful transplant. Read more about Mary's story here. 

 

 

References:

¹ Kidney Transplant Access in the Southeast: View from the Bottom. American Journal of Transplantation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167710/

² Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management. Kidney International Reports. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5720531/

 

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