With his extensive background in medical technology and a deep focus on driving innovation, Faisal Zain has become a leading voice in the application of value-based care to solve some of healthcare’s most persistent challenges. Today, we’ll delve into his insights on transforming care for chronic kidney disease, a condition affecting more than one in seven American adults yet often remaining undiagnosed until its latest, most dangerous stages. Our conversation will explore how data-driven, value-based models can revolutionize early detection, address the stark gender and racial disparities that plague kidney care, and integrate medical, social, and behavioral health data to create truly holistic treatment plans. We will also touch on how these models empower patients facing difficult treatment decisions and consider the broader future of value-based principles across chronic disease management.
Chronic kidney disease is often called a ‘silent disease,’ with many patients unaware they have it until the late stages. What specific, data-driven VBC strategies can providers use to improve early detection, and what metrics best demonstrate success in identifying at-risk populations before symptoms appear?
This is precisely where value-based care fundamentally shifts the paradigm from reactive to proactive. Since upwards of one in three adults with late-stage CKD don’t even know they have it, we can’t wait for symptoms. A key VBC strategy is leveraging data to identify at-risk individuals and then wrapping them in preventative care. This means a heightened emphasis on routine, consistent monitoring of key indicators like blood pressure and A1C levels, especially for patients with known risk factors like diabetes or hypertension. Success isn’t just about treating the disease; it’s about preventing its progression. The metrics that truly matter here are forward-looking: we track the rates of preventative screenings across our patient populations, monitor strict adherence to prescribed medications, and watch for reductions in hospital readmissions. When we see screening rates go up and readmissions go down, we know we’re successfully catching and managing the disease early, long before it becomes a crisis.
Women are at a higher risk for CKD but are often diagnosed later than men. Within a value-based care framework, how can multidisciplinary teams proactively address gender-specific risk factors, like autoimmune disease or pregnancy complications, to ensure timely diagnosis and referral for female patients?
This is a critical equity issue that VBC is uniquely designed to address. The fact that women are less likely to be diagnosed or referred, despite higher risk, is a systemic failure. In a value-based model, we move beyond generalized plans. A multidisciplinary team—involving primary care, nephrology, social workers, and behavioral health specialists—collaborates across the care continuum. For female patients, this means their health history is viewed holistically. A history of lupus, for instance, or a pregnancy complicated by pre-eclampsia, becomes a flag in the system that triggers a personalized care pathway. This isn’t just a note in a chart; it’s an action item. The team can then ensure regular kidney function tests are ordered and that the patient is educated on her specific risks, ensuring that a referral to a nephrologist happens at the earliest appropriate moment, not years later when significant damage has already occurred.
African Americans experience higher rates of kidney failure and mortality from CKD. How can VBC models specifically leverage population health data to correct for underrepresentation in clinical trials and design care interventions that more effectively reduce these severe racial disparities? Please provide a step-by-step example.
This is one of the most powerful applications of a VBC approach. Given that African Americans constitute only 9% of participants in CKD clinical trials, we can’t rely on generalized study data. We have to use our own population health data to see what’s really happening. First, a VBC provider would aggregate and analyze its data, stratifying by race. It might identify, for example, that African American patients are experiencing a faster progression of CKD compared to white patients with similar comorbidities. Second, the system flags this as a critical disparity. Third, the multidisciplinary team digs deeper to design a targeted intervention. This isn’t a one-size-fits-all solution; it could be culturally competent patient education about diet, increased pharmacist consultations to ensure medication adherence, or more frequent telehealth check-ins. Finally, and most importantly, the provider continuously tracks performance metrics specifically for this group to measure if the intervention is successfully slowing disease progression and closing that mortality gap.
VBC models aggregate disparate data to risk-stratify patients. Could you walk us through how a health system can integrate medical, behavioral, and social data to build a predictive model, and how that model helps care teams prioritize interventions for the most vulnerable CKD patients?
Certainly. This integration is the engine of personalized, whole-person care. Imagine a patient’s file. The system pulls clinical data from the electronic medical record—lab results showing declining kidney function, high blood pressure readings. It then integrates notes from a behavioral health specialist indicating the patient is struggling with depression. Finally, it adds information from a comprehensive intake assessment, which includes screening for social determinants of health, revealing the patient has unstable housing and is facing food insecurity. A predictive model analyzes these disparate data points together. It recognizes that this combination—medical, behavioral, and social barriers—puts the patient at an extremely high risk for hospitalization. The model immediately flags this individual, and the care team can prioritize an intervention. A care coordinator is deployed not just to discuss medication but to connect the patient with housing resources and a local food bank, understanding that without this stability, no medical plan will succeed.
Unlike traditional fee-for-service models, VBC aims to address social determinants of health. Can you share an anecdote or a specific example of how a VBC provider successfully helped a patient overcome barriers like food insecurity or housing instability to improve their kidney health outcomes?
I recall a case involving a gentleman with advancing CKD who was consistently missing appointments and his lab numbers were worsening. Under a fee-for-service model, he would have simply been labeled “non-compliant.” But in our VBC system, a comprehensive assessment revealed the root cause: he was living in a motel room without a kitchen and relying on fast food, which is devastating for kidney health due to the high sodium and phosphorus. He also had no reliable transportation to get to the grocery store or his appointments. Our multidisciplinary team stepped in. A social worker connected him with a local agency that helped him secure stable, subsidized housing with a full kitchen. A dietitian then worked with him, teaching him how to cook simple, kidney-friendly meals. We also arranged for a transportation service for his medical visits. Within six months, his blood pressure stabilized, his lab markers improved, and he was an active, engaged participant in his own care. We didn’t just treat his kidneys; we addressed the life circumstances that were making him sick.
When CKD progresses, VBC models prioritize patient choice and strategic planning for dialysis or transplantation. What does this “optimal initiation of dialysis” look like in practice, and how do care teams ensure the approach is truly personalized to align with each patient’s unique preferences and life circumstances?
“Optimal initiation” is a profound departure from the old way, where a patient often crashed into dialysis in an emergency room. In practice, it’s a carefully planned and deeply personal journey. Long before dialysis becomes urgent, the care team initiates conversations with the patient and their family. We educate them on all treatment modalities—in-center hemodialysis, peritoneal dialysis at home, or pursuing a pre-emptive transplant. The key is that this is a shared decision. We discuss how each option would impact their life. Does the patient work full-time and need the flexibility of home dialysis? Is their primary goal to travel, making transplantation the priority? This strategic planning ensures that if and when dialysis is needed, it begins in a controlled, outpatient setting, often with a permanent access site already in place. It’s about giving the patient agency and control over their treatment, aligning their medical care with their life goals, which leads to better health outcomes and higher patient satisfaction.
What is your forecast for the role of value-based care in managing chronic conditions beyond kidney disease over the next five to ten years?
My forecast is that value-based care will become the standard, not the exception, for managing all complex chronic diseases. The principles we see succeeding in nephrology—proactive care, holistic data integration, addressing social determinants, and coordinating multidisciplinary teams—are universally applicable. Whether it’s for congestive heart failure, diabetes, or COPD, the fee-for-service model is fundamentally broken because it only pays for sickness, not for health. The next decade will see a significant acceleration of VBC adoption as payers and providers recognize that it is the only sustainable path to improving population health, reducing devastating health disparities, and controlling costs. It represents a move toward a more intelligent, humane, and equitable healthcare system that treats the whole person, not just the disease.
