Why CKD Patients Fall Through the Cracks and How Healthmap Bridges the Gaps

Physicians know how to treat chronic kidney disease (CKD). What they can’t see is everything that happens after a patient leaves the office. In this episode of The Strategy of Health from The American Journal of Healthcare Strategy, host Cole Lyons talks with Howard Shaps, MD, MBA, who was Healthmap Solutions’ Chief Medical Officer when the episode was recorded, about why CKD patients fall through the cracks and how Healthmap’s care navigators help close the gaps.

From the emergency department to population health

Dr. Shaps practiced emergency medicine for 16 years, then earned his MBA and worked in consulting with CMS, pharmacy benefits, and health insurance, including a national role as deputy chief medical officer. He has cared for countless patients with kidney disease and end-stage kidney disease, and has seen the problem from the clinical side and the payer side. At Healthmap, he gets to address it at the population level, with technology behind it.

The gap outside the four walls

“The docs are really good. They know what they’re doing. What they don’t have are eyes and ears outside their four walls.” (Dr. Howard Shaps)

Patients forget to fill prescriptions. They lack transportation. They leave appointments without understanding what they were told, through no fault of the provider. Dr. Shaps said Healthmap’s care navigators hear this all the time. By coordinating care, educating members, and passing information back to physician offices, Healthmap acts as an extension of the care team. One example: making sure a stage 5 patient sees a surgeon for dialysis access well before dialysis starts.

Why health plans partner instead of building in-house

Cole asked why a health plan wouldn’t build this capability itself. Dr. Shaps pointed to more than 10 years of building the program:

• A risk stratification engine built on millions of lines of claims, lab, and other data that predicts which members are most likely to have an acute event in the next 12 months.
• Automated detection of care gaps, such as missed medications, lapsed provider visits, needed lab tests, and recent emergency or inpatient use.
• A leadership team with deep health plan experience, which makes it easier to take on risk and grow deliberately.

The results are consistent across clients: fewer unnecessary hospitalizations, fewer emergency department visits, fewer readmissions, and slower CKD progression.

Focusing on preventable utilization

Healthmap’s focus is unnecessary admissions, emergency visits, and readmissions, the ones tied to preventable conditions. Many CKD patients also have heart disease. Helping a provider see which medications a patient is or isn’t taking, and where a change might help, can keep that person out of the hospital. That’s better for the patient, and it supports quality and Star Ratings for health plans. (Related reading: Reducing CKD Hospitalizations Through Proactive Care Coordination.)

Finding CKD earlier

Healthmap starts with members at stage 3. Primary care physicians manage many of these patients well, and with a nationwide nephrologist shortage, working through PCPs lets Healthmap reach far more people. Dr. Shaps has seen cases where someone assumed their kidney function was normal and it wasn’t. Prompting the right lab tests helps catch disease earlier, sometimes even in stage 1 or 2. It’s a large population: the CDC estimates that about 14 percent of U.S. adults, or 37 million people, have CKD.

Preparing for later stages

For members in stages 4 and 5, navigators build trust first, then start conversations as early as possible about transplant (always the preferred option) and dialysis, including the benefits of home dialysis. Healthmap uses knowledge assessments before and after education to measure readiness. Dr. Shaps said the approach has increased planned dialysis starts, reduced “crash” starts, and increased home dialysis rates. (See What to Expect When Starting Dialysis and Dialysis Access Options.)

Behavior change takes repetition

From his years in the emergency department, Dr. Shaps knows how little time clinicians have to influence behavior. Primary care is just as busy.

“It’s hard to change behavior overnight, and it’s hard to change behavior in a 15-minute conversation. Repetition goes a long way.” (Dr. Howard Shaps)

That’s where an ongoing relationship with a caring nurse or navigator helps: seeing the doctor, staying on medications, and addressing diet, lifestyle, and social and behavioral needs.

Listen to the full episode

Find the episode page on AJHCS, watch on YouTube, or listen on Apple Podcasts or Spotify. Learn more about Healthmap’s CKD care management.