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Within the U.S. healthcare system, in the past decade, there has been an accelerating shift away from traditional fee-for-service (FFS) payment models towards models focused on rewarding quality while lowering the total cost of care. This emphasis on value, not volume, offers opportunities to pay for comprehensive holistic care not available in a traditional FFS approach.��

Ģ����ý has been a pioneer and leader in value-based care (VBC) since 2014. The company created Interwell Health (Interwell) in 2019, a joint venture with nephrologists dedicated to working together in the transition from volume to value. This led to an innovative merger in 2022 between Fresenius Health Partners, the companyĢ����ý�s VBC division; Interwell Health, the leading nephrology provider network; Cricket Health, a pioneering digital technology and patient engagement company; and Acumen, the leading nephrology-specific electronic health record (EHR) built on the Epic platform.��

Today, the new Interwell is growing rapidly to serve the needs of more than 122,000 people with chronic kidney disease (CKD), including those with end-stage kidney disease (ESKD), across a national scale and broad payer mix. Interwell is the largest participant and quality-leader in the government models for kidney care, while also contracting with large national and regional private insurers. The keys to InterwellĢ����ý�s future success are implementing strategies that delay CKD progression, effectively managing the transition to ESKD for those whose kidney disease progresses, and reducing hospitalization and mortality rates for patients with advanced kidney disease.

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Implementing New Care Models at Scale

To be successful, any value-based company must deliver results for patients and payers at scale backed by a sustainable financial model that includes both shared and full-risk contracts.��

Interwell focuses on people living with CKD beginning in stage 3 through ESKD, managing people with significant disease burden complicated by social needs. InterwellĢ����ý�s care model centers around a team that includes dietitians, social workers, nurses, and care coordinators, working with a personĢ����ý�s nephrologist and primary care physician. InterwellĢ����ý�s model allows us to support the right patients at the right time wherever they areĢ����ý�at the doctorĢ����ý�s office, in their home, or at a dialysis center. InterwellĢ����ý�s model includes many unique aspects such as:��

Predictive Analytics:��Risk stratification for patients using InterwellĢ����ý�s proprietary machine learning models to identify those most at risk of progression or hospitalization. Many of these machine learning capabilities were relaunched in 2023 to provide better accuracy over a longer period. Knowing who InterwellĢ����ý�s patients are, what they need, and when they need it to manage their kidney disease drives the effectiveness of InterwellĢ����ý�s clinical interventions.��

Largest Provider Network: Collaboration with more than 1,800 nephrologists aligned on the incentives for improving outcomes. InterwellĢ����ý�s care team approach is to move away from a siloed and fragmented healthcare delivery system to one that has both the patient and providers at the center.��

Acumen Epic Connect:��Most-adopted EHR built for nephrologists with new population health tools, access to EpicĢ����ý�s Care Everywhere, and custom dashboards. Interwell Care Connect and Acumen Epic Connect enhance seamless communication of care between providers.��

Dialysis Center Alignment:��For those people transitioning to dialysis in one of Fresenius Kidney CareĢ����ý�s 2,600 clinics, we offer coordinated remote care management focused on identifying patients at the highest risk for hospitalization within seven days as well as post-hospitalization transition management. This offers more timely interventions such as adjusting the dialysis prescription to better address adjusting clinical targets such as estimated dry weight.��

Care Transition Program:��Rapid outreach by a dedicated care team for all patients discharged from the hospital to ensure a visit with their nephrologist within 14 days.��

While there are many aspects to InterwellĢ����ý�s VBC program, this discussion focuses on how the program addresses two of the largest drivers of costs.

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Reducing Hospitalizations

Hospitalizations are not only expensive but create substantial burdens for patients and their caregivers. In addition, discharge from a hospital stay is a transition of care that can fragment patient care absent detailed attention to care coordination. The work to keep people healthier and out of the hospital has a major impact on the health and well-being of the population and success in a VBC program. Approximately one-third of the annual medical costs for Medicare beneficiaries for people living with CKD and ESKD are a result of inpatient hospitalization. InterwellĢ����ý�s program focuses on managing patients holistically to prevent avoidable hospitalizations.¹

InterwellĢ����ý�s Care Transition program empowers a team to reach out to patients post-discharge to ensure they see a nephrologist within two weeks. InterwellĢ����ý�s analysis of more than 11,000 members showed that those who visited a nephrologist within 14 days of discharge were almost 25 percent less likely to be readmitted within 30 days than those who did not see their doctor (Figure 1). The results of all these efforts are healthier patients, fewer hospitalizations, and lower costs for payers.²

For one national Medicare Advantage payer, Interwell managed 7,500 members with ESKD to reduce costs per member per month (PMPM) by 4.22 percent, at a time when the Medicare fee-for-service benchmark rose by approximately 10 percent. Over a five-year period (2017Ģ����ý�2022), admits per member per year dropped from 1.71 to 1.34, while readmissions dropped from 23 to 18 percent (Figure 2).

For a smaller regional payer, Interwell successfully reduced all-cause hospitalizations among people with late-stage CKD by 25 percent, lowering rates from a baseline of 1.06 admits per member per year (PMPY) to 0.79 PMPY over two years (2021Ģ����ý�2022). For all people with ESKD, all-cause hospitalizations were lowered by 30 percent, from a baseline of 1.65 admits PMPY to 1.16 PMPY. These efforts resulted in a 13 percent lower cost of care and total savings of $3.6 million for this regional plan (Figure 3).

Improving Optimal Starts

The latest government payment model, Kidney Care Choices (KCC), rewards physicians for optimal starts. This is defined as transitioning from CKD with a pre-emptive kidney transplant, home peritoneal dialysis (PD), or starting home hemodialysis or in-center hemodialysis with a permanent arteriovenous (AV) access (AV graft or AV fistula) but not with a tunneled catheter. United States Renal Data System (USRDS) data show that up to 85 percent of new hemodialysis starts include some type of catheter.¹��A recent retrospective study found that optimal starts decrease post-dialysis costs by $16,565 per patient per year when compared to unplanned starts.³

Interwell utilizes a combination of resources to help practices improve optimal starts:��

• Predictive analytics to help identify and target higher-risk patients��
• Kidney disease education course and patient materials (Interwell Learning)��
• Interwell Renal Care Coordinators (RCCs) embedded in physician practices��
• Performance-based programs that align clinical and financial goals

Approximately one-third of the annual medical costs for Medicare beneficiaries for people living with CKD and ESKD are a result of inpatient hospitalization.

Since the companyĢ����ý�s first contract in VBC in 2014, RCCs have been embedded into physician practices to help with care transition and education. This program now totals 80 RCCs embedded in 50 practices across the country. In the remaining situations, Interwell leverages remote nurses who work with patients telephonically in coordination with the practice. Interwell works closely with its nephrology partners to develop the specific processes, education, and training needed to drive success in the KCC program.��

Interwell has also developed a specialized learning program for nephrology practices to use with their patients with CKD. In 2023, InterwellĢ����ý�s affiliated practices using the Interwell Learning kidney disease education program observed a 68 percent optimal start rate, compared to a 57 percent optimal start rate for practices not using this program.

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Real-World Impact��

The shift to value requires new ways of working and more holistic approaches to care delivery. While the data already shows cost savings and improved outcomes, itĢ����ý�s each story behind that data, from a pre-emptive transplant to delayed progression, that is a reason to celebrate the potential of value-based care.