Over nearly two decades building technology for diagnostics and treatment, I’ve seen how tools either liberate clinicians to focus on care or trap them in paperwork. Value-based kidney care is one place where the model, the team, and the tech finally pull in the same direction. In this conversation, we dig into how a practice reframed purpose coming out of the pandemic, stood up physician-led pathways, embedded renal care coordinators, adopted a nephrology-specific EHR, participated in CMS’s Kidney Care Choices model, and shifted culture so plans were executed between visits. We also explore financing the transition, easing physician burden, and what parts of nephrology’s playbook other specialties can adapt without losing their own identity.
You practiced nephrology in eastern North Carolina for nearly 25 years—what moments first signaled that fee-for-service was eroding your purpose, and how did missed meds, transportation gaps, or confusion about plans show up in clinic? Share one patient story and the downstream clinical and cost impacts.
The warning lights started blinking when ten-minute check-ins replaced real conversations, and the problems we could fix only surfaced after they spiraled. I remember a patient from rural North Carolina who missed two doses of new blood pressure meds because his ride fell through and he didn’t grasp the change in his pill color—by the time he reached clinic, swelling and fatigue had worsened. In a fee-for-service world, nothing funded a phone call to catch that early wobble, and the cascade was predictable: an avoidable trip to the ER, a short admission, and a dent in trust that made our next visit harder. The human cost—fear, confusion, and a family scrambling for transportation—was what stayed with me, and it’s exactly what value-based care is designed to interrupt.
Take me inside that eight-hour Saturday meeting when your group decided to go all-in on value-based care. Who spoke up first, what objections surfaced, and what criteria or evidence finally tipped the vote? Walk through the sequence of decisions you made that day.
It was a long, honest Saturday that began with fatigue and ended with resolve. The first voice was a quiet one, a partner who admitted he no longer recognized the profession he loved; that opened the door for frontline stories about fragmented care and missed chances between visits. Objections came fast—how to fund resources up front, how to manage risk when most revenue still flowed through fee-for-service, and who would lead the culture shift. What tipped us was the clarity of our north star—outcomes over volume—and a concrete plan: appoint physician leads for ESKD, CKD pathways, transplantation, quality, and operations; educate the entire staff on value-based principles; choose a partner with purpose-built tech and care coordination; and commit to measure what matters, even if returns were two to three years out.
You said FFS rewards episodes rather than long-term outcomes. Can you map a typical CKD patient journey under FFS versus VBC, step by step, and highlight when early intervention changes the trajectory? Include timelines, touchpoints, and any measurable differences in hospitalizations or progression.
In FFS, a CKD patient often ping-pongs: primary care flags a lab, a consult is scheduled weeks out, a brief visit adjusts meds, then radio silence until the next flare. Transportation hiccups or confusion about a sodium restriction can go unnoticed, so the first “intervention” becomes an acute episode. In VBC, the arc changes immediately: intake triggers a risk stratification in a nephrology-specific EHR, a renal care coordinator calls within days to reconcile meds and map barriers, and dietitian and social work touches happen between visits. The result is fewer late surprises, earlier dialysis planning, and, in our first year under CMS’s Kidney Care Choices model, an 84% optimal start rate that reflects fewer unplanned, hospital-driven beginnings to dialysis.
You appointed physician leads for ESKD, CKD care pathways, transplantation, quality metrics, and clinical operations. How did you define those roles, select leaders, and set accountability? Describe the first 90 days: goals, dashboards, meeting cadence, and one early course-correction that mattered.
We wrote crisp charters for each lead—what outcomes they owned, what data they’d review weekly, and which decisions required group consensus. Selection favored clinicians who could blend bedside realism with process discipline; the ESKD lead, for example, was the person colleagues already called when a plan went sideways. In the first 90 days, we set goals tied to optimal starts, transplant referral readiness, and core quality measures, then built a dashboard in the nephrology-specific EHR to surface “missed opportunities.” Our earliest course-correction was cadence: we moved from monthly to biweekly huddles because too much drifted between meetings, and that single change tightened follow-through.
You embedded renal care coordinators in clinics—something FFS couldn’t fund. What does a high-performing RCC week look like, and how do they track adherence, barriers, and follow-through? Share two patient anecdotes and the metrics you use to gauge RCC impact.
A strong RCC week blends proactive reach-outs with rapid problem-solving: daily med checks on high-risk patients, transportation confirmations, home BP review, and quick loops to dietitians or social workers. We use structured notes in the EHR—barriers tagged, adherence logged, open tasks with due dates—so nothing relies on memory. One patient story: an RCC noticed a lag in portal messages, called to learn a daughter who managed meds had started a new job, and arranged blister packs and a neighbor check-in; symptoms settled, and the next clinic visit focused on goals rather than rescue. Another: an RCC heard background wheezing over the phone, triggered an urgent clinic slot, and prevented a weekend spiral. We track early plan completion and contribute directly to that 84% optimal start rate, which is a concrete signal the model is working.
Dietitians, social workers, and APPs became core team members. How did you scope their responsibilities to complement physicians, and what training or protocols ensured consistency? Give a case where social support changed a clinical outcome, including time to improvement and cost avoided.
We designed complementary lanes: physicians set diagnoses and long-term trajectories; APPs managed protocolized adjustments; dietitians translated plans into daily habits; and social workers tackled the life hurdles that derail good medicine. Consistency came from shared playbooks—common labs, counseling scripts, and handoff templates—embedded in the EHR. One case stands out: a patient about to start dialysis kept missing education visits; the social worker discovered a caregiving burden at home and coordinated respite services and a ride, and the patient completed training without a hospital-driven start. The improvement was swift—by the next visit, confidence replaced fear—and the avoided acute start spared both the patient and the system the disruption that typically leads to an admission.
You adopted a nephrology-specific EHR to see the full patient journey. Which data fields or alerts proved most actionable, and how did that change daily workflows? Walk through a “missed opportunity” the system flagged and the exact intervention steps that followed.
The most actionable elements were longitudinal eGFR trends, dialysis access readiness, transplant referral status, and “barrier” tags that RCCs and social workers could update in real time. Alerts were tuned to surface what matters: overdue education, med reconciliation gaps, or transport risks before key visits. One missed opportunity the system flagged was a patient with declining eGFR who had no documented access plan; the alert triggered a same-day RCC call, a scheduling hold for education, and a physician review to finalize the pathway. Within days the plan was in motion, a quiet save that we never would have caught reliably in a generic EHR.
In your first year in CMS’s Kidney Care Choices model, you hit an 84% optimal start rate and a perfect quality score. What were the three biggest drivers behind those results, and how did you operationalize them? Share baseline metrics and month-by-month improvements.
Three drivers stood out. First, embedding RCCs to ensure plans were executed between visits—this made the difference between intention and action. Second, physician-led pathways with clear ownership for ESKD, CKD, and transplantation—no ambiguity about who acted when. Third, a nephrology-specific EHR that turned data into early action, not just documentation. We began with the same baseline challenges most practices face and built momentum by making weekly progress visible; by year’s end, the 84% optimal start rate and a perfect quality score validated that our operational choices translated into patient outcomes.
You mentioned shifting administrative load off physicians. Which tasks moved to whom, and what processes or tools enabled that handoff without dropping balls? Give before-and-after time studies per visit and describe how that changed your conversations with patients.
Medication reconciliation and transportation logistics shifted to RCCs; diet education moved to dietitians with standardized curricula; and documentation templates in the EHR pre-populated quality fields so physicians didn’t hunt for data. The handoff worked because responsibilities were codified in checklists, tasks lived in the EHR with owners and due dates, and huddles closed loops. Before, a visit felt like a scramble; after, the work before and between visits let us spend time on decisions and coaching. The qualitative shift was palpable—more eye contact, fewer clicks, and room for patients to tell us what mattered to them.
Financing was front-loaded with returns two to three years later. How did you structure risk, cash flow, and reserves during the transition, and what partner capabilities were non-negotiable? Outline your ROI timeline with milestones and guardrails you wish you’d had earlier.
We treated the transition like building a bridge while still driving on the old road: maintain FFS revenue, carve out reserves, and invest early in care coordination and tech with a clear glidepath to shared savings. Non-negotiables in a partner were analytics that could surface the right patients at the right time, contracting expertise to manage risk, and care coordination muscle to execute plans between visits. The ROI timeline hinged on early signals—care plan completion and optimal starts—flowing into performance under models like CMS’s Kidney Care Choices; we expected the meaningful return two to three years in. If we could rewind, we’d formalize guardrails earlier—contingency reserves tied to phase gates—so we could pace investment with proven adoption.
Culture change was central. How did you educate front-desk and clinical staff on VBC, and what messages or visuals made it stick? Describe one early skeptic, how you won them over, and the specific performance signals that shifted team sentiment.
We started with why—stories of missed connections and how value-based care fixes them—and then showed how every role contributes to outcomes. Visuals mattered: a simple journey map from first referral to dialysis or transplant, with dots for each touchpoint and names under each dot so ownership was clear. One longtime scheduler was skeptical, worried this was just new jargon for more work; we paired her with an RCC, and when she saw a plan carry through between visits—rides confirmed, education completed—her skepticism gave way to pride. The tipping point for many was seeing that 84% optimal start rate and hearing a physician say, “The plan from the last visit was fully executed,” which made the change tangible.
Your partner said plans were “fully executed” between visits. What system made that true—checklists, outreach protocols, or escalation rules? Walk through a typical between-visit cycle, including frequency of touches, who contacts whom, and how you audit completion.
It was a layered system: standardized checklists tailored to risk, outreach protocols that scheduled cadence, and escalation rules for when issues surfaced. A typical cycle began with the RCC reviewing the EHR dashboard, calling the patient to confirm meds and transportation, looping in dietitians or social workers as needed, and documenting tasks with due dates. If barriers persisted, a physician or APP stepped in with a targeted touch. Completion was audited in weekly huddles, where open tasks were visible to the whole team—no black boxes, no wishful thinking.
Trust can erode when volume trumps relationships. How did you rebuild trust with patients under VBC, especially in rural North Carolina? Share two communication strategies, one misstep you corrected, and any patient-reported outcome or satisfaction trends you tracked.
We led with clarity and continuity: plain-language plans and a consistent point person between visits. Two strategies helped: teach-back to confirm understanding and proactive calls before key milestones so patients felt guided, not summoned. Our misstep was assuming the patient portal was enough for everyone; in rural areas with patchy internet, a phone call or mailed summary mattered more, and we adjusted quickly. As trust deepened, patients told us they felt “seen” and “less alone,” and that qualitative feedback aligned with smoother starts and the performance we achieved in models like KCC.
Only 14% of provider reimbursement is tied to VBC today, double three years ago. What policies, payer moves, or specialty-led models could accelerate that curve, and where might bottlenecks arise? Offer concrete steps for nephrology, cardiology, and oncology to scale responsibly.
Policy can catalyze growth by expanding specialty-focused models, smoothing data sharing, and aligning quality measures across payers so clinicians aren’t chasing different targets. Payers can support the build by front-loading resources—care coordination and tech—recognizing returns often arrive two to three years later. Bottlenecks include fragmented data and uneven readiness for risk. For nephrology, continue refining pathways and care team roles; for cardiology, build heart-failure–specific coordination with frequent between-visit checks; for oncology, integrate navigation and symptom management protocols that prevent avoidable acute care, always keeping outcomes—not touch counts—at the center.
For a specialty practice considering VBC now, what is your step-by-step 6-month playbook—talent, technology, contracts, and quality metrics? Include must-track KPIs, a sample outreach calendar, and the first risk you would intentionally take.
Month 1–2: name physician leads, hire or reassign coordinators, and select a purpose-built EHR or enhance your current one with specialty modules. Month 3–4: standardize care pathways and outreach protocols, stand up dashboards for core quality metrics, and train everyone from front desk to APPs on roles and handoffs. Month 5–6: pilot with a defined cohort, tighten workflows based on weekly huddles, and finalize contracts that align incentives. Track optimal starts or equivalent specialty outcomes, plan completion, and quality scores; run a simple outreach calendar—weekly for high risk, biweekly for moderate—and take the first intentional risk by investing in coordinators before the savings arrive, because the work between visits is what changes the trajectory.
Interwell Health is your platform today. What capabilities—analytics, care coordination, contracting, or clinical pathways—mattered most, and how did they integrate with your EHR and team routines? Give one example where partner support directly prevented a hospitalization.
The combination of analytics to surface rising risk, care coordination to execute plans, and contracting support to navigate models like KCC was essential; it meant we didn’t have to invent infrastructure while learning a new model. Integration with a nephrology-specific EHR created a single source of truth, so analytics translated into tasks and tasks into completed actions. One example: a partner alert flagged a patient trending toward an acute start; within the workflow, an RCC made same-day contact, a dietitian adjusted the plan, and the physician confirmed the access pathway—an intervention that kept the patient on track and out of the hospital. That is the promise of the platform: insight meets execution without friction.
Looking back, where did VBC not work as expected, and how did you pivot? Share a metric that stalled, the root cause you uncovered, and the exact process changes that restarted progress within one quarter.
Early on, plan completion stalled despite strong clinic visits. The root cause wasn’t motivation; it was mismatched follow-up—too much reliance on digital messages for patients who preferred calls or needed help with transportation. We shifted to phone-first for high-risk patients, tightened escalation rules, and moved to biweekly huddles so delays couldn’t hide. Within a quarter, those changes showed up in smoother execution and fed into the strong outcomes we achieved.
For clinicians struggling with burnout, what moments in your VBC journey restored purpose? Describe one patient relationship that changed, the time you reclaimed per week, and how that affected teaching, mentorship, or community outreach.
Purpose returned when the space to listen came back—when a visit wasn’t consumed by hunting for information or arranging rides. One relationship transformed after consistent between-visit support: a patient who used to arrive anxious began bringing questions and ideas, and our conversations felt like teamwork again. With administrative load shifted to the right roles, I reclaimed meaningful time each week to teach and mentor, and to support community education in rural areas. That ripple effect—better care today, more resilient clinicians tomorrow—is as valuable as any metric.
As nephrology is viewed as a model for other specialties, what elements are truly transferable and what must be specialty-specific? Compare referral patterns, risk stratification, and team composition, with examples of how you would adapt each.
Transferable elements include physician-led pathways, embedded coordinators, and an EHR tuned to surface missed opportunities and track quality. Specialty-specific adaptations matter in referral timing, risk flags, and which disciplines anchor the team—cardiology might center heart-failure protocols, oncology would elevate navigation and symptom triage. In all cases, build around what happens between visits because that’s where outcomes are shaped. The key is honoring the specialty’s rhythms while holding fast to the VBC core: outcomes over volume and teamwork over heroic individualism.
If you had to convince a skeptical board tomorrow, what three slides would you show—baseline outcomes, cost curves, and patient experience—and what numbers would be on each? Walk me through the narrative you’d deliver in three minutes.
Slide one: baseline outcomes and fragmentation—missed opportunities between visits and late interventions that everyone recognizes from lived experience. Slide two: the value-based arc—team roles, pathways, and platform capabilities—anchored by two anchors from our first year in CMS’s Kidney Care Choices model: an 84% optimal start rate and one of only three perfect quality scores in the country. Slide three: patient voice and clinician voice—“plans fully executed between visits,” trust restored, and a clear path to scaling. The story is simple: we invest up front, execute between visits, and replace episodic care with a continuous relationship that pays off in better outcomes and a more sustainable practice.
Do you have any advice for our readers?
Start with purpose and make it operational—assign owners, build the workflows, and choose partners who turn insight into action. Invest early in the people who work between visits because that’s where plans either die or come to life. Keep your dashboards brutally simple and your huddles frequent; momentum is built in the small, consistent moves that compound over time. And remember the “why”: value-based care isn’t just a payment model—it’s a path back to the kind of medicine that drew you in, where outcomes and relationships matter more than the number of encounters.
