Groundbreaking Population Health Strategies for Chronic Kidney Disease

What does it take to manage the health of 150,000 to 200,000 people with chronic kidney disease (CKD) without losing sight of the individual? In this episode of The Strategy of Health from The American Journal of Healthcare Strategy, Healthmap Solutions CEO Eric Reimer, fresh off his EY Entrepreneur Of The Year win, walks host Cole Lyons through Healthmap’s population health approach step by step: finding the right members, working with the providers they already trust, and proving value to health plans.

Step 1: Define the right population

Healthmap starts with data on members who have kidney disease and members who might: anyone diagnosed with diabetes, hypertension, or heart disease. It looks for diagnosis codes and for lab results that show kidney disease even when it hasn’t been coded. Because kidney function tests are objective, lab results can confirm the stage.

Getting the population right means avoiding false positives too. A hospital stay coded as kidney disease may really be an acute kidney injury, not CKD, so Healthmap looks for confirmation across settings or a confirming lab test. As Eric put it, the goal isn’t to be overly inclusive. It’s to find the members Healthmap can help most.

Step 2: Find the providers members trust

Next, Healthmap identifies which physicians each member actually sees. It doesn’t impose a narrow network. Usually that’s a primary care physician, and hopefully a nephrologist, cardiologist, or endocrinologist, though often no nephrologist is involved yet.

Step 3: Risk stratify and customize at scale

Using claims, pharmacy, and lab data, Healthmap predicts who is most likely to have an adverse event or progress to the next stage in the coming year, and prioritizes the most intensive support for them. Because Healthmap is responsible for members’ total health, not just their kidneys, its systems build a customized care plan for every member. A relatively healthy stage 3 member and someone with end-stage renal disease need very different things. (See our Population Health Management approach.)

Getting the data

Cole asked how Healthmap gets data plans often don’t have. Eric was candid: there’s no single answer. Health plans typically have lab data from the large national labs. Healthmap also works with health information exchanges and physician offices, and sometimes asks members to self-report. When there is no recent lab result, the team helps the member get one, which is also another chance to connect them with their doctor.

Caring for the whole person

Healthmap’s work with members falls into two buckets. The first is removing barriers: behavioral health screening and referrals, food insecurity, housing, transportation, and help with medication copays. Eric stressed that identifying social needs is only the first step. The job is to close the gap, often by connecting members with local organizations. (See Screening for Social Determinants of Health.)

The second is education and adherence: helping members understand their condition, stay on their medications even on days they feel fine, and set realistic diet and exercise goals.

Going all in on Puerto Rico

Many advised that launching in Puerto Rico would be difficult. Healthmap decided to invest fully: an office on the island, more than 70 local staff across every region, and, for the first time, local leaders empowered to customize the program. Eric called it one of the best-run operations he has seen. (Read Healthmap’s success in Puerto Rico.)

Making providers more effective

“We’re not trying to steer members away from providers at all. We’re really trying to make the providers that they’ve already chosen to be more effective.” (Eric Reimer)

Healthmap asks each member’s providers to endorse the program, and it makes the case with specifics, such as a patient who hasn’t filled a statin prescription in 90 days, rather than general promises. For primary care, kidney patients may be only 5 to 10 percent of a panel, so Healthmap fits each practice’s workflow, whether that’s the EMR, a central nurse hub, or individual physicians. For nephrologists, whose time is scarce, Healthmap provides action-oriented data and handles much of the member education about their disease and dialysis options. (Learn more on our Providers & Health Systems page.)

Proving value to health plans

Healthmap only gets paid when it improves clinical outcomes and saves money: better medication adherence, fewer admissions and readmissions, more members seeing nephrologists, fewer crash dialysis starts, and slower progression. Eric emphasized that Healthmap doesn’t deny care. It invests more in physician visits, labs, and medications up front, and in every case that investment has been more than offset by fewer inpatient stays. (Related: Value-Based Kidney Care.)

Listen to the full episode

Find the episode page on AJHCS, watch on YouTube, or listen on Apple Podcasts or Spotify.