Health Plan Strategies for Better Care

How should a health plan choose who to trust with its members who have chronic kidney disease (CKD)? In this episode of The Strategy of Health from The American Journal of Healthcare Strategy, host Cole Lyons talks with Dr. Beth Malko, a family physician and health plan executive with nearly 30 years of experience, about the challenges plans face in CKD management, the central role of primary care, and why plans should look for clinical partners instead of vendors.

A systems view of health care

Dr. Malko started her career as an environmental engineer before moving into medicine. In family practice, she found herself drawn to system-level fixes. Her large group practice took on Medicare and Medicaid risk in the 1990s, and succeeded, which led her into a long career helping health plans deliver affordable, high-quality care.

Primary care as the quarterback

For patients with serious conditions, Dr. Malko said the health care system isn’t built to make the connections that need to be made. Primary care physicians are. A newly diagnosed kidney patient may suddenly need a nephrologist, a vascular surgeon, and a dietitian, and may also have heart disease. Someone has to make sure a cardiologist doesn’t prescribe something that works against their kidney care.

“It was critically important to have that quarterback that the PCP really is, especially in people with complex illnesses.” (Dr. Beth Malko)

What health plans can see

Health plans often know more than providers realize. They see every claim: which specialists a member visits, where they were admitted, and whether prescriptions are being filled on schedule. Dr. Malko’s example: a physician switches a patient’s blood pressure medication because it isn’t working, when pharmacy data would have shown the patient was only filling it half as often as prescribed. Plans are increasingly sharing this information with primary care through portals and partnerships, within the limits of federal privacy rules.

She singled out one thing Healthmap does that she rarely sees: working directly on the connection between primary care physicians and nephrologists. That was one of the reasons she chose to work with Healthmap.

Clinical partners, not vendors

With AI point solutions everywhere, Cole asked how plans should choose. Dr. Malko laid out her criteria:

• A capability the plan can’t build. Even the largest plans won’t staff dozens of nephrologists or oncologists.
• Skin in the game. The old model tied contracts to service levels like call answer times. Partners should be measured on outcomes, such as lower emergency and hospital use and better quality scores, with fees at risk if those outcomes don’t happen.
• Real collaboration. Problems will come up during implementation on both sides. A good partner picks up the phone and fixes them.
• References, relationships, and geography. Talk to similar plans. Favor partners already working with you in related areas, and partners who know your state, its Medicaid program, and your providers.

She was blunt about stacking point solutions around a single disease. It doesn’t make sense. (For a health plan view on this, see The Value of a Kidney Population Health Management Program.)

Why the CMO should own the decision

Clinical partner decisions belong with the chief medical officer, who typically runs the total medical expense committee. A well-vetted proposal with fees tied to outcomes is an easy case to make to the CFO and CEO. Dr. Malko also advised plans to offer partners one standard data set rather than building custom files for each one, and to treat data exchange as seriously as the clinical program, since clinical solutions don’t work without accurate data.

How primary care practices benefit

Physicians’ first reaction to another outside program is usually “no thanks.” Dr. Malko said the approach matters. Start with larger and at-risk groups, meet with both clinical and business leaders, and make the offer clear: CKD is hard for primary care, and the partner will help identify patients earlier, get them to a nephrologist sooner, and manage them between visits. She said that works about 90 percent of the time.

She sees nephrology and oncology as outliers where patients tend to “disappear” into specialty care. Early CKD, especially stages 2 and 3, is frequently missed in primary care, and managing it well means adjusting medications, diet, and much tighter control of diabetes and hypertension. That’s a lot to take on alone. (See Do Primary Care Providers Have the Time for Kidney Disease Management?)

Listen to the full episode

Find the episode page on AJHCS, watch on YouTube, or listen on Apple Podcasts or Spotify. Health plans can learn how Healthmap works as a risk-sharing clinical partner on our Health Plans page.