Podcast - Scaling Success in Value-Based Kidney Care

In this episode of Kidney Health Connections, Dr. Carney Taylor, former co-president of Eastern Nephrology Associates in Greenville, NC, shares how the practice achieved a perfect quality score in the government’s value-based Kidney Care Choices Model and an impressive 84 percent optimal start rate during his tenure. Dr. Taylor highlights the importance of care coordination and data, as well as how the practice drove cultural and leadership changes to realize the full potential of value-based care in improving patient outcomes. In addition, he discusses how Eastern Nephrology navigated the challenges of caring for patients across a large, mostly rural, area in a fragmented healthcare system.

Dr. Taylor sat down with Interwell Chief Medical Officer Dr. George Hart to record this episode ahead of the 2024 Interwell Health Partner Summit, where the company first announced that Dr. Taylor would be transitioning from his seat on Interwell’s board to a full-time role on the medical office leadership team. During the conversation, Dr. Taylor also shares how he plans to champion value-based kidney care and a patient-first approach in his role as associate chief medical officer of Interwell.

Disclaimer:

The statements contained in this podcast are solely those of the participants and do not necessarily reflect the views or policies of CMS. The participants assume responsibility for the accuracy and completeness of the information contained in this podcast.

Transcript:

Welcome to Kidney Health Connections, a podcast exploring the future of kidney health and the rapid shift of value-based care where you can learn about the latest innovations that are helping patients live healthier, more fulfilling lives. Here's your host, Dr. George Hart.

Dr. George Hart: In 2022, as part of the Advancing American Kidney Health executive order, CMS's Center for Medicare and Medicaid Innovation launched the Kidney Care Choices Model, further testing the latest iteration of a value-based care approach to kidney care. Year one results are in, and only three out of 50 participating entities achieved a perfect quality score. One of those practices is Eastern Nephrology Associates, which covers the eastern third of North Carolina.

Today we're fortunate to have Eastern's long-time co-president, Dr. Carney Taylor, who's agreed to share some of the secret sauce which led to their success, while also providing some pearls along the way which practices can incorporate into their approach to caring for patients.

Carney, thanks for joining us today. It's really nice to have you here.

Dr. Carney Taylor: Thank you.

Dr. George Hart: You worked in eastern North Carolina now for a long time. You're from that area. Give us a little insight on your practice, and I'm particularly interested, in that you cover such a wide geographic area, how you've sort of overcome some of those challenges and not just, you know, creating a broad network of coverage down there, but also being so successful in a value-based care format.

Dr. Carney Taylor: Yeah, thank you. So I grew up in eastern North Carolina. It's a little town, about 11,000 people. So it's near and dear to my heart. Being able to go back and practice there for close to 25 years now has just been an amazing opportunity.

Eastern North Carolina, it's a beautiful area of the country. It's very rural though. There are a couple larger communities that my practice covers 150- to 200,000 people. But the majority of our patients live in communities that are average in size, 5,000 to 30,000. And many of our patients live a pretty good distance away from, you know, typical healthcare areas of service. We have patients that have to travel an hour and a half to an in-center dialysis unit.

My practice has grown over the years. We now have 36 nephrologists and about 27 advanced practitioners. We cover 20,000 square miles, ranging from the Virginia-North Carolina border in the north down to the South Carolina-North Carolina border in the South. And we operate in pods. So a pod would typically be anywhere from two to three nephrologists up to the larger pods, which have about 10 to 12. And the pods are centered around hospitals that provide inpatient dialysis care.

We're also rounding in over 60 dialysis clinics across the countryside. We have multiple CKD clinics. And so as we work day to day, we work in sort of mini nephrology practices, but we're all coupled together in one business structure. And we've really taken a lot of effort, a lot of time, to make sure that we're all in the same boat, we're all rowing in the same direction. And I think that's been a critical part of our practice.

The healthcare in east North Carolina has been historically fragmented, in my opinion. There are different hospital systems that are not the same across where we practice. The primary care physicians can be part of larger systems, but many of them are still independent and private. There are multiple different electronic health records that we have to engage in outside of our practice. So it's been a wonderful place to work. But in terms of value-based care, it has definitely presented some obstacles for us in terms of defragmenting what our patients have to navigate.

Dr. George Hart: So I'm going to put you on the spot here a little bit, maybe even make you blush, because Eastern Nephrology was one of three practices, like I mentioned earlier, that had a perfect quality score out of 50 in the first year of CMMI's KCC model. Your optimal start rate, almost 85%, which lapped the field, if you will, regarding most of the other players. How do you do this? How do you organize what you've just alluded to as kind of a fragmented healthcare system covering thousands of miles of territory? How did you put all this together to get these incredible patient outcomes?

Dr. Carney Taylor: It's probably worth kind of talking about it from two different directions. I'll start with some of the philosophies that we had and some of the organizational commitments that we made. And then I'll get into maybe some of the details about optimal start and how we were able to achieve that number.

So we got our foot wet in the value-based care program back with the ESCO program six or seven years ago. And we recognized that times were changing, that there was probably a new payment model that was going to be coming forth. And we looked into it very diligently, we studied why, we studied how it worked, and we got together and we made a commitment as a group. The owners of the practice spent an entire Saturday in the midst of COVID, or in the first couple months of COVID, in a virtual meeting. And after about eight hours, we committed to building a value-based care program or building or putting infrastructure into our practice that could make us successful in value-based care.

So there was an early commitment that we had, and then we rapidly recognized that we had to change the culture of our practice; that fee-for-service was vastly different than value-based care. And so we intentionally invested in sort of changing our culture. We wanted to make sure that every single person, every employee in the practice knew what value-based care was and knew why we were doing it, and that they saw it through the lens of the ultimate goal, which is the patient gets a better outcome.

So, you know, we knew our clinical team would know about value-based care; they're the ones delivering the care. But we wanted to make sure our front desk people knew as much about it as well, that they could be instruments of the ears, hearing patients as they come in—the voice of making sure patients hear what they need to hear when they're checking out about following up with us. And so we invested very heavily in educating our team on what we wanted to do.

And then it got into sort of a real strategic plan. And the plan was to create leaders in our practice that had various roles in overseeing the value-based care. We appointed a medical director of the value-based care program. We had somebody who oversaw the transplant efforts, somebody who was involved directly with the quality metrics. These were all physicians who took ownership of these different lanes. And through that, through their investment of time, they helped to create the culture that I think was so important for us in our outcomes.

Value-based care is hard. You're investing in something that brings returns in the future. And you have to be very focused on the ultimate goal so you don't get beat up and bruised as you go forward. But we were able to create this culture and work through that.

When it came down to optimal starts, which I think was the other part of your question, we relied very, very heavily on care coordination. We had the relationship with Interwell as we entered into the CKCC model. So we had Interwell care coordinators that were able to come into our offices and be a part of our team seamlessly and really help make sure that the plans of care that had been created by patients were transacted, that the patient was able to navigate the system and get what they wanted out of it. So that was helpful, care coordination.

Data was critical. We needed to have access to real-time data that was accurate. We needed to know what we were getting right and what we were getting wrong. And I think data continues to evolve dramatically.

We didn’t set our bar on whatever the CKCC optimal start goal was. Can you remember in the first year maybe 60% or so was the optimal start target? Our goal was 100%.

We wanted every one of our patients to be able to have an optimal start. And so I think our providers would see it as a personal failure if they had a patient who crashed into dialysis. And we really rallied the team around making sure that didn't happen. And so lots of focus in different areas. I can elaborate on any of them.

Dr. George Hart: I think what I would like you to mention, though, is I'm pretty familiar with eastern North Carolina and the geography that you cover and the sort of disparate nature of the different markets. You have an EHR, it happens to be the one that Interwell owns, Acumen, connected to Epic. Maybe you can elaborate on how having an EHR that's VBC friendly, if you will, helped you, given the geographies that you're trying to cover and herding cats, if you will.

Dr. Carney Taylor: Well, the EMR has a number of different important contributions that it makes to the outcome of the patient. Number one, it's the repository of the plan of care. And what I like to see is that there are multiple people who are engaged in that plan of care that's created. It's created by the doctor and the patient in a very intimate way. But then that plan of care needs to be touched and reviewed and engaged with by multiple other members of the team. And so having the ability to in real-time change that or document in and affect the plan of care, where all the members of the team can see it, is critical and Acumen, the EMR, teases that out.

It's also at the point of care where certain data indicators or signals can come up and really influence the provider in making sure that gaps of care are closed. And so, you know, in our EMR, it will signal us if the patient has not had an appropriate encounter or they've missed a visit or they've, they've done whatever. I think it's really a phenomenal tool in helping us to understand where the gaps of care are. And it's evolving very rapidly as we go forward and becoming more and more a critical component of what we do.

Dr. George Hart: You also have an investment that you've made in care coordination and particularly renal care coordinators. I think it would be helpful for this audience to get a better understanding on how, what role they play in advancing, you know, the care for patients.

Dr. Carney Taylor: You know, when you have advanced kidney disease, you're sick, you don't feel well, it's hard to keep up with everything the physician said in the clinic visit. It's hard to follow all the appointments and details.

And so I think of the care coordinator as sort of, they have a number of hats—one is coach and the other is friend. And they really just come in and attach themselves to the hip of the patient virtually or via phone or other ways that they can engage the patient. They just check in on them, they make sure that the patient is following through with the steps of the plan of care that are so important.

They're also there to provide reassurance, to identify barriers that would lead to a missed appointment or, you know, anything else that could sort of derail the plan. And so they're leaning in.

But I think coach, right, they're educating, they're teaching. Friend, they're listening, they are there in a very compassionate manner attached to that patient. It's been really, really helpful for us.

Dr. George Hart: Yeah, I mean, I'm sure your experience is like mine was in a traditional fee-for-service world. You come up with a great treatment plan, you think you've communicated it, and then the patient and their family leave the office and nothing happens. You know, they're overwhelmed, they didn't understand a word you said, or just paralyzed or they have other issues that get in the way.

So I love this idea of, you know, friend, confidant, sometimes maybe even parent, holding accountability. So, yeah, a great sort of way to describe it all.

You guys really seem to be on the leading edge for how you've embraced the changes that need to be made with value-based care. You know, how do we take your learnings and share this more broadly so that we can replicate it, even though we know that every market's a little different.

Dr. Carney Taylor: Well, I think Interwell is so blessed to have such a rich network of physician practices around the country. And I think that we share all of our practice successes, whether it's my practice or in other practices and you proclaim it from the mountaintop and you share how you got to that point. It's not easy and it's going to look a little bit different in every practice and in every market. But I think just sort of the spirit of collaboration amongst the network is a critical way to do it.

I also think that we, practices, Interwell, have an obligation to advocate, and advocate at the level of the payers, the level of the government, because I think we would all once you get into value-based care and you look at the outcomes, the patients are getting a much better outcome. And I think that we need to be advocates for that. I mean, there's a lot that we should do and can do to show our successes.

Dr. George Hart: You've been, you said from the very beginning you're an eastern North Carolina fellow at heart, you have a very dear love for the area, but you're not staying. Spoiler alert: by the time folks are broadly hearing or seeing this broadcast, you're going to be part of Interwell; you're going to join the medical office. And we are so excited to have you be a part of it. And excited too for the extra platform that you'll have to do these things. What do you want to tell these practices?

Dr. Carney Taylor: Yeah, well, first of all, I'm thrilled about the opportunity. After having practiced now for close to 25 years, I've recognized that despite how much I've tried, sometimes my patients don't land where they deserve to land. And value-based care for me has shown me that there's an opportunity to improve that. So I'm coming into Interwell just thrilled with the opportunity to champion the entire industry forward.

I think Interwell is the lead value-based care company. Just the incredible assets that have been brought together, the unique way in which Interwell engages practices and meets them where they are, a true partner in value-based care, and to be a part of that is just so exciting for me.

So I'm going to lean in. I obviously have a lot to learn about the industry and about Interwell, but I think we just keep the main thing, the main thing, and that is: patients first. We figure out what patients need, we figure out a way in which we can support those needs. And at the end of the day, I think that that's where we want to be and the companies that do that well will be successful.

Dr. George Hart: Yeah, I totally agree. And thanks for all those insights on optimal starts. You know, obviously a lot of energy and effort with changing that workflow, but it's not the only quality measure that was part of the CKCC program. Patient activation measures, depression screening were also important. You guys did a great job with those as well. Maybe share with us how you got there.

Dr. Carney Taylor: So those two measures, there's a lot of logistics behind them. Capturing the interviews at the right time with the patients, making sure that if the patient scored positive on either of the two tests that there's a clinical response or there's a leaning into the patient to acknowledge that. So we relied pretty heavily on both Interwell's resources and then resources we developed in our own practice to be able to achieve those metrics.

I'll give you a bit of an example. When you are doing the depression screening, you have to make sure you're capturing that at the right time. But then if you have a patient who scores high, which is a signal of depression, the clinician needs to react to that. It needs to be brought to their attention. So we actually had to develop some sense of understanding of how to interpret the test as a clinician and then how to respond. And that could be a variety of different responses, whether it's refer out to get some help from a clinical psychologist or a psychiatrist, or to manage internally through counseling and medications. So we had to develop a program around that, which we did. And our providers, some felt very comfortable managing depression on their own and some didn't. And we created pathways for both.

From a logistic perspective, the interaction with Interwell was critical. We shared spreadsheets and kept data logs of who had had the test done. And the renal care coordinators were very helpful in this. They were overseeing many of the episodes of care when the patient would come in and they were able to signal the team, “Hey, we have to get this done while they're here today.” So truly a test of both operational and clinical efforts to get it done correctly.

Dr. George Hart: Yeah. Yeah, that's great. Thank you. Before we started this, I gave you a crystal ball and you've been looking into it. You know, what do you see three to five years from now? Where's the future? What do you think is going to be the two or three things that really change the game?

Dr. Carney Taylor: It's a great question and I've had a couple days to think about it and I still don't have the absolute answer, you know, but I think there's going to be an evolution for sure. I don't think that value-based care tomorrow will look exactly like it looks today. I think that there's going to be a lot more focus on disease prevention and slowing of progression to end-stage kidney disease. It is encouraging that we finally have some tools in our tool bag to deploy and I think that Interwell and practices like mine can be stewards of those tools and can really begin to change the outcome of kidney disease.

There will always be people who unfortunately end up needing transplants or need to start dialysis, but I think that our focus on their earlier stage disease will bring them to that point in a much healthier and more stable condition than many of our patients are at when they start dialysis today.

So I think that's very exciting for the future. I think that there's a ton of opportunity around transplant and what we can do to enhance the transplant experience and get more people on the waiting list and subsequently transplanted. And I think value-based care is positioned well to be a partner in that effort.

I think we're going to have to deal with the fact that, as the quarterback of the patient, as the nephrologist being the quarterback, there are some tools that I don't have access to. I think that we may need to be creative and engage other subspecialties into the models, whether it be endocrinology or podiatry or vascular surgery or whatever things are really driving the outcomes of our patients. How do we get them, or those subspecialties, to kind of lean into the care as part of the value- based offering? So I think that's going to be a big item over the next three to five years that we have to figure out.

Dr. George Hart: Yeah, I couldn't agree with you more. And you know Carney, this has been great. We could probably talk for hours and really appreciate the insights you bring, the leadership that you've brought to Eastern Nephrology and are now going to share with Interwell and look forward to having you join the team.

We hope you'll join us for more conversations on the future of kidney care by subscribing to Kidney Health Connections on the listening app of your choice and visiting our website at interwellhealth.com.