Reducing Care Fragmentation to Boost CKM Disease Outcomes

Am J Manag Care. 2025;31(Spec. No. 3):SP157-SP161. https://doi.org/10.37765/ajmc.2025.89711

One of primary care’s most pressing challenges is cardio-kidney-metabolic (CKM) disease, which encompasses chronic kidney disease (CKD), diabetes, heart failure, obesity, and cardiovascular disease (CVD). Its interconnected nature emphasizes a need for integrated, patient-centered care and multidisciplinary collaboration to reduce care fragmentation.

On December 5, 2024, the Institute for Value-Based Medicine held an event in partnership with the University of Pittsburgh Medical Center (UPMC) in Pennsylvania with the theme, “Population Health Models for Cardio-Kidney-Metabolic Disease in Primary Care.” Presentations underscored the importance of offering proactive, holistic care while ensuring health equity, financial accessibility, and improved outcomes for patients with complex, chronic conditions. The speakers also addressed social determinants of health and their roles in disease management, health informatics and data-driven treatment recommendations, multidisciplinary care models to improve care coordination, value-based care for sustainability and cost-effectiveness, and advanced therapeutics and technology integration.

“We need to come together so that all specialties are giving holistic recommendations to the patients and not have our own little silos of care,” said Manisha Jhamb, MD, MPH, associate chief, codirector of clinical research, and associate professor of medicine, Division of Renal-Electrolyte, and director, Center for Population Health Management, University of Pittsburgh, and the evening’s chair. She was joined by the following experts from across the UPMC space:

• Jaideep Behari, MD, PhD, director, UPMC Fatty Liver, Obesity, and Wellness Clinic
• Ellen Beckjord, PhD, MPH, vice president, Population Health and Clinical Optimization, UPMC Health Plan
• Gary S. Fischer, MD, medical director, eRecord Ambulatory Decision Support and Analytics, UPMC
• Linda Fried, MD, MPH, staff physician, VA Pittsburgh Healthcare System
• C. Bernie Good, MD, MPH, senior medical director, UPMC Health Plan Insurance Division
• Esra Karslioglu-French, MD, endocrinology specialist, University of Pittsburgh Physicians, Department of Endocrinology
• Mary E. Keebler, MD, medical director, Center for Advanced Heart Failure, UPMC Heart and Vascular Institute
• Barbara S. Kevish, MD, medical director, UPMC Health Plan
• Jared W. Magnani, MD, MSc, associate professor of medicine, Division of Cardiology, University of Pittsburgh

Endocrinology Care

“The total cost of diabetes is around $400 billion, making it the most expensive chronic disease. People with diabetes have health care costs 2.6 times greater than those without diabetes,” Karslioglu-French noted in her presentation on endocrinology care. “If we can control this disease, we can prevent complications, make people healthier, and decrease costs.”

Of the 38 million people with diabetes in the US, most receive their diabetes care from primary care physicians (PCPs), even with complications such as CVD, kidney failure, blindness, and lower-limb amputation, she said.

Karslioglu-French noted that UPMC’s initiatives in this space are 2-fold:

• The Targeted Automatic eConsults (TACos) program uses clinical analytics to identify high-risk patients with uncontrolled disease so endocrinologists can proactively recommend treatment on the day of a patient’s appointment. Results show a 21% drop in hemoglobin A_1camong TACos participants compared with 10% among a general population, lower hospitalization rates, and increased uptake of glucagon-like peptide-1 receptor agonists (GLP-1s).
• The CDC Certified Diabetes Care and Education Specialist program targets patients with uncontrolled disease who have high rates of health
  care utilization. It works with UPMC Health Plan to eliminate the need for referrals and continuous billing, allowing easier access to certified diabetes educators without co-pay concerns. Data from 2000 patients show reduced hemoglobin A_1c levels; total, medical, and pharmacy costs; and 30-day readmission, as well as higher rates of continuous glucose monitoring—for a savings of nearly $8 million.

“With these initiatives,” Karslioglu-French explained, “we are now able to look at patients as a whole.”

Heart and Vascular Care

“We all know that heart failure is increasingly common,” Keebler noted, opening her discussion on UPMC’s Heart Failure Medication Optimization Clinic (HFMOC), a referral-based telemedicine clinic for patients who have heart failure with reduced ejection fraction (HFrEF). “It leads to high mortality and morbidity, and it is expensive, with projected costs reaching $70 billion yearly by 2030.”

Nearly 3 million individuals in the US have HFrEF, with the current standard of care being a comprehensive disease-modifying quadruplet therapy: β-blockers; angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNIs); aldosterone antagonists (also known as mineralocorticoid receptor antagonists [MRAs]); and sodium-glucose cotransporter 2 (SGLT2) inhibitors. The therapy is based on an all-cause mortality 26% absolute risk reduction seen in clinical trials, with the goal of achieving the target doses seen in those trials.^1,2

However, the traditional path of sequential prescribing has proven ineffective for UPMC’s population because of barriers that include inconsistent follow-up, the need for frequent in-office visits, communication delays, and coverage costs. The HFMOC employs structured algorithms so advanced practice providers and clinical pharmacists can optimize guideline-directed medical therapy within 12 weeks to facilitate rapid treatment initiation and medication uptitration, with the goal of reducing heart failure–related hospitalizations and mortality. Conventional sequencing can take 6 months or more—from ACE inhibitors/ARBs to beta-blockers to MRAs to ARNIs to SGLT2s. However, the HFMOC’s proposed approach—from beta-blockers and SGLT2s to ARNIs to MRAs—condenses this into 4 weeks before initiating uptitration, reducing the time to reach guideline-recommended doses.

“We face challenges in health care based on pricing and financial models,” Keebler concluded. “Payers and providers need to come together to help work through these barriers.”

Renal Care

Currently, 1 in 7 adults in the US has CKD, a number that could rise to 1 in 6 by 2030, Jhamb said in her presentation on UPMC’s nephrology care model. One in 3 people with diabetes and 1 in 5 with hypertension develop CKD, she explained. Unlike diabetes or heart failure, what makes CKD so dangerous, she added, is that it is a silent disease—90% of patients are unaware they have it—and it carries a 4-fold higher risk of CVD. The disease is also very costly, with annual expenses exceeding $124 billion for patients who have CKD and end-stage kidney disease; dialysis alone can cost $90,000 annually, Jhamb noted.

Nephrology is in a transformative era, she continued, integrating SGLT2 inhibitors, GLP-1s, and the MRA finerenone to delay kidney disease progression and improve cardiovascular outcomes. Recent updates to clinical guidelines reflect consensus among national kidney, diabetes, and heart societies on integrating these advancements into CKD treatment, but implementation lags, taking an average of 17 years to translate research into practice, Jhamb explained.

She talked about the recently completed Kidney Coordinated Health Management Partnership trial (Kidney-CHAMP; NCT03832595) that evaluated the effectiveness of population health management in CKD. During an October 2024 AJMC Stakeholder Summit,³ Jhamb noted: “We designed this program to comanage some of our high-risk CKD patients along with PCPs because we felt like that was where the bulk of our patients were. A lot of these patients, because they don’t know they have kidney disease, are not seeing a nephrologist, and then they have rapidly worsening kidney disease and end up with crash start dialysis.”

Kidney-CHAMP integrated health informatics tools, population health dashboards, and clinical decision support to help PCPs identify and treat high-risk patients. As with the endocrinology care model, TACos were used to provide concise recommendations and served as educational tools for PCPs. Pharmacists also provided medication management, reconciliation, and simplification to improve adherence and outcomes.

The UPMC CKD program, supported by a value-based care model, expanded to 102 primary care practices across 13 counties to address rural health equity. Engaging 3000 patients, the program staff conducted more than 6000 e-consults, 5000 medication reviews, and 4700 education sessions. Patients received biannual follow-ups, and renal palliative clinicians were integrated to guide treatment decisions. Social workers assisted with medication access, transportation barriers, and food insecurity.

The focus was on scalability, adaptability to new guidelines, and long-term population health strategies by addressing CKM syndrome and psychosocial determinants of health, as well as defining CKD outcome metrics. Financial sustainability was a key consideration, with future efforts in the space including exploring alternative payer models, value-based contracts with drug manufacturers, and industry partnerships to develop new care models for patients with high-risk CKD.

“We really have to use our informatics and try to identify the high-risk patients who are going to benefit the most from this kind of a complex care model,” Jhamb concluded. “How can we partner with our industry partners to align our goals with the industry goals? I think this is a space that might evolve, and this is something that we need to be open about.”

Population Health Challenges

Population health challenges in the US are vast and accelerating, driven by environmental, social, and economic factors that make it difficult to prioritize health. “There really is no shortage of challenges,” Beckjord noted. She said modern conveniences discourage healthy behaviors and that many people struggle to balance life, work, and wellness, with a lack of autonomy over time being a major determinant.

One key issue is the misalignment between health care incentives and population health. “Our population health is a function of cultural and community factors that are extremely difficult to influence,” Beckjord pointed out. Health plans and providers have significant control over the services they provide, but interventions alone rarely drive large-scale improvements. This is because network contract and payment model structures play a crucial role in shaping systemic health outcomes, she said.

Beckjord critiqued value-based payment models for failing to provide key reinforcement criteria, pointing to such factors as weak financial incentives and delayed rewards or penalties. This misalignment fosters a system less focused on preventing illness and more focused on treating illness so that population health initiatives fail to gain a foothold, she said.

She suggested the following strategies to improve outcomes and move the needle toward a more proactive approach to population health:

1. Refine value-based models to meet healthy behavior reinforcement criteria
2. Reduce the need for incentives by making healthy choices the default
3. Leverage social reinforcement within provider-patient relationships

The Prescription for Wellness initiative at UPMC Health Plan exemplifies this approach by integrating referrals into provider workflows, which helps patients access preventive services without overly burdening clinicians. Clinicians often don’t have enough quality time to spend with each patient—something that has not changed much in the past 2 decades. Research from 2007 shows a median physician visit length of 15.7 minutes,⁴ whereas data from 2023 show visits peaking at 18.9 minutes.⁵

Ultimately, she advocated for stronger collaboration between payers and providers to design innovative care models that transcend the limitations of the current system, foster trust, and make preventive care more accessible by working toward a model that prioritizes health preservation over reactive treatment.

Multidisciplinary Collaboration and Reducing Care Fragmentation

The first panel discussion, “Innovative Models of Care: Integrating Care Amongst Providers,” examined the interconnected nature of CKM syndrome, with Magnani emphasizing that “it really is the tip of the iceberg” in terms of undiagnosed risk.

Primary care faces challenges in prevention, polypharmacy, and lifestyle interventions, the panel agreed. This is particularly clear in an environment that “nudges patients toward obesity and metabolic problems,” Fischer stated. Magnani highlighted rural populations’ heightened CKM risk caused by social determinants, noting that “80% of health is due to our environment and social factors” and that obesity was “the elephant in the room.” Karslioglu-French warned of obesity’s impact on multiple specialties, including oncology and neurology. Behari stressed that fatty liver disease is central to CKM and that even though it affects 90 million individuals in the US, it remains “seriously underrecognized.” Fried underscored the economic burden of CKM syndrome, stating, “It [costs] billions upon billions of dollars a year.”

The panelists concurred that integrating specialty input into kidney care models is necessary to reduce fragmentation. To accomplish this, Fischer stressed that primary care needs both guidelines and decision support tools that can evolve with time “because there’s a challenge in delivering lifestyle interventions to our patients and in giving them the tools and the skills to make changes so that they can lead a healthy lifestyle.”

Magnani emphasized something similar, “a precision model that is multidisciplinary and collaborative” to address patient education and adherence. At the VA, Fried explained, they use pharmacy, case managers, and social workers to comanage CKD. Also important to these efforts are electronic medical records and GLP-1 receptor agonists, Behari and Karslioglu-French added.

Despite these advancements, however, reimbursement challenges remain, underscoring the need for systemic changes to support integrated, patient-centered kidney care and early intervention in cardiometabolic disease.

The second panel discussion, “Health Plan Perspective on Value-Based Care,” addressed the challenges of transitioning from fee-for-service to value-based care and emphasized the need for risk-adjusted hybrid payments to support the comprehensive care required with CKM syndrome. Kevish stated that “until we get to hybrid payments...we’re never going to get anywhere” and advocated for more time to address patients who have CKM syndrome.

Beckjord highlighted the importance of efficient, multidisciplinary care, noting that because patients don’t see themselves as divided by disease states, “we have to think at a benefit design and payment model level.” Good shared UPMC’s holistic approach: “We’ve tried to focus on those technologies that have the greatest impact.” He also praised UPMC’s decision to make diabetes medications more accessible for Medicare patients, improving adherence and patient outcomes.

The panelists also discussed strategies to address financial toxicity and improve value-based care, with one suggestion being to collaborate with industry
partners through value-based contracts—such as outcomes-based agreements to evaluate the effectiveness of therapies—and another emphasizing the importance of incentivizing both PCPs and specialists. They noted that resourcing infrastructure and educating physicians on risk adjustment and data interpretation are essential, as are direct outreach to patients to improve engagement and outcomes in value-based care models to ultimately lower costs and improve outcomes.

Overall, the panel emphasized the critical role of multidisciplinary care models that focus on efficiency and waste reduction while incorporating holistic approaches to optimize patient outcomes. Integrating better data interpretation and providing strong infrastructure support for PCPs were identified as pivotal elements for successful collaboration with industry partners for an effective transition to value-based care. By focusing on these strategies, health care systems can offer more comprehensive, efficient, and patient-
centered care, leading to better outcomes and lower costs for complex patient populations.

Author Information: Ms Shaw is an employee of MJH Life Sciences, the parent company of the publisher of Population Health, Equity & Outcomes.

References

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2. Vaduganathan M, Claggett BL, Jhund PS, et al. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: a comparative analysis of three randomised controlled trials. Lancet. 2020;396(10244):121-128. doi:10.1016/S0140-6736(20)30748-0

3. Exploring the Kidney-CHAMP study. AJMC. October 14, 2024. Accessed February 8, 2025. https://www.ajmc.com/view/exploring-the-kidney-champ-study

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