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Nephrologist Timothy Pflederer discusses his article “How value-based care transforms chronic kidney disease management,” highlighting how value-based care (VBC) is reshaping the treatment of chronic kidney disease and end-stage kidney disease. Timothy explains how VBC encourages continuity of care through interdisciplinary teamwork, empowers long-term patient engagement, and addresses health inequities that disproportionately affect minority populations. He emphasizes that shifting from a volume-based to a value-based approach supports prevention, improves outcomes, and enhances patient experiences. Listeners will walk away with actionable takeaways on how VBC supports whole person care, integrates support services, and builds a sustainable future for chronic disease management.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Timothy Pflederer, he is a nephrologist, and today’s KevinMD article is “How value-based care transforms chronic kidney disease management.” Tim, welcome to the show.

Timothy Pflederer: Thanks, Kevin. It is good to be here.

Kevin Pho: All right, so let us briefly share your story and then jump straight into your article and why you decided to write it.

Timothy Pflederer: I am a nephrologist. I have practiced for over thirty years in Peoria, Illinois, which is central Illinois, kind of the heartland. As a part of that, our practice began to transform the work we do from fee-for-service to value-based care to take care of people with advanced kidney disease. About one and a half years ago, I transitioned into the role as chief medical officer for Evergreen Nephrology because I really thought that value-based care was providing a different level and a better level of care to our patients than what we were doing, no matter our best efforts under fee-for-service.

Kevin Pho: All right, so tell us some of the challenges physicians face, especially nephrologists, when it comes to kidney care.

Timothy Pflederer: Our patients are very complex. They have multiple medical problems in addition to their chronic kidney disease. Our health care system is well-proportioned to take care of acute illness and has a much more difficult time managing patients who have polychronic disease and really have multiple needs to be coordinated across multiple providers over an extended period of time. I think value-based care provides the infrastructure to do that in a different and better way.

Kevin Pho: And when you talk about value-based care as it specifically relates to chronic kidney disease management and care, what exactly do you mean by that?

Timothy Pflederer: Well, at Evergreen, what we try to do is partner with a nephrology practice so that we are working with the nephrology provider as a team, supplementing what a provider cannot do. A provider does excellent work at the point of care making clinical decisions and helping to educate their patient, but between the office visits, the provider really does not have a picture of that patient. We are able to bring a care management team (a care navigator, a PharmD, a registered dietitian, a social worker) to really wrap around the patient between office visits and support them, to bring education, to bring help with social determinants of need, and also to just monitor the patient and bring changes back to the nephrologist so that we can intervene proactively.

Kevin Pho: Now, let us take a step back. For those people who are listening and may not be familiar with the effects and symptoms of chronic kidney disease, from a patient’s perspective, what are some of the things that they need to look out for in between visits to your doctor?

Timothy Pflederer: Unfortunately, for many people, they do not really know that they have kidney disease until it is relatively advanced. It is silent until it may get to the stage where their GFR, or glomerular filtration rate, is low enough that they really are having difficulty keeping up with metabolic processes. So they may start to develop edema. They might start to lose their appetite. They may lose their energy related to either uremia or anemia. The problems that people with kidney disease face are the complications of the kidney disease as well as complications of their comorbid diseases, like managing their diabetes, managing their hypertension, and their heart failure. We help patients monitor those things and help them identify early on what needs they have so that we can hopefully keep them healthy, active, and out of the hospital.

Kevin Pho: So tell me, in terms of the type of outcomes that this multidisciplinary approach has, does it reduce hospitalizations and death, and if so, what is some of the data behind that?

Timothy Pflederer: Yeah, we have been able in our data to see that we have a profound impact on quality as we bring a patient into the program very quickly. One thing we look at is an optimal start to dialysis, meaning a smooth transition to dialysis if that is what the patient needs, where they are healthy and out of the hospital. Our optimal start rate across the country for nephrologists used to be in about the twenty percent range, and now we are running sixty, seventy, and even eighty percent in some of our practices where patients start dialysis educated, at home, on home dialysis, or with a permanent dialysis access.

We have seen hospitalization be reduced, and readmission rates go down. We have seen a delay in the progression of kidney disease. It is an early signal yet, but by getting more patients on SGLT2 inhibitors, making sure they are on ACE inhibitors, and making sure their diabetes and high blood pressure are controlled, we are seeing that those that we are managing, compared to those that we are not, have a lower rate of progression of chronic kidney disease. So hopefully that will translate into fewer people crossing into needing a kidney transplant or dialysis.

Kevin Pho: So just to give us a better picture of the scenarios, can you contrast this interdisciplinary approach that we are talking about today with what normally happens without this approach? Give us a couple of stories or scenarios.

Timothy Pflederer: Absolutely. When I would see a patient in my office before I had the support of a care management team, I would see the patient, talk to them about their kidney disease, maybe adjust their blood pressure medicine, and I would encourage them to follow their blood pressures at home. I would answer questions, and I would schedule them back three months from then. I thought during the course of that visit that I had educated the patient and they understood their disease, they understood where they were and what they needed to do, and indeed understood their medications.

The truth is that often they came back three months later and they either did not follow what I had asked them to do or just did not report when something changed that I thought I had given them instructions for. So, having a team who is able to reinforce the message that I have given, provide even more education to the patient, and then touch base with them over the course of that three months has made a big difference in the patient being supported. The patient and their family understand what their treatment plan is and are then able to follow that and stay healthy. That is not something that I could do even with an office staff as a nephrologist.

Kevin Pho: Now tell us the type of patients who would be eligible for this multidisciplinary approach.

Timothy Pflederer: So currently, we have a number of different opportunities to engage patients. Under Medicare fee-for-service, there is a specific program called the Kidney Care Choices (KCC) Model, and patients are able to be aligned into that and have that benefit as a part of their Medicare. Many Medicare Advantage plans as well provide the opportunity to be a part of a risk-based contract where a nephrologist and value-based care management company like Evergreen can engage with a patient. Value-based care is even moving into commercial and Medicaid populations. So it is becoming more and more available to patients, but for the typical nephrologist, they are still managing many of their patients under fee-for-service without that additional level of support.

Kevin Pho: Now are programs like these typically available only in academic-affiliated medical centers or urban areas? What about outside of cities?

Timothy Pflederer: That is a great question. They are available across the board and, indeed, probably more common in private practice. In situations with academic centers, it is more difficult to engage a patient in that holistic way. They can engage them very well in highly specialized tertiary care, but value-based care is certainly throughout primary care in the non-academic setting. Now specialty-focused, value-based care is available urban, rural, and in private practice or in larger health systems. The challenge is that many patients have trouble accessing it because of other disparities in health care, like socioeconomic disparities and racial disparities that we see are particularly heavy or impactful in people with kidney disease.

Kevin Pho: So you talk a lot about those disparities in your article. Specifically as it relates to that, how does value-based care address those disparities in kidney disease outcomes?

Timothy Pflederer: We are able to bring a greater level of support to patients who have social determinants of health needs, and that can really support people who are in especially socioeconomic and racial minorities. For instance, often for a patient who is on dialysis, one of the biggest challenges is just transportation, getting to their dialysis treatment and home. Under a value-based care situation, we can bring resources to bear to ensure that a patient actually has transportation. We can address food insecurity. We can address housing insecurity because we are using dollars, if we do this well, that would have been spent on the patient during their hospitalization. We are preventing that hospitalization and are able to use those dollars in more preventive, upstream care. And that is really proving to be true.

Kevin Pho: Now, from the patient perspective, for someone who might be listening to you now and thinking this sounds pretty good, how can they go about looking for clinicians or centers that take this value-based care approach to their chronic kidney condition?

Timothy Pflederer: Today, value-based care is really based upon the patient’s insurance. So, the way a patient could explore this is by looking to their insurer, whether that is Medicare, Medicare Advantage, or Medicaid, to see under what policy or program they might be able to access a value-based care arrangement. There are more and more of those available.

Kevin Pho: We are talking to Timothy Pflederer, he is a nephrologist, and today’s KevinMD article is “How value-based care transforms chronic kidney disease management.” Tim, let us end with some take-home messages that you want to leave with the KevinMD audience.

Timothy Pflederer: I believe that our patients with chronic kidney disease have many severe medical problems that are difficult to care for in isolated, episodic care. What value-based care allows is for us to bring a team of providers to wrap around the patient, walk the journey with the patient, and help that patient and their family live their life as they want to live it, to the fullest. I am excited about how that is transforming care for those patients and hope more have access to that over time.

Kevin Pho: Tim, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Timothy Pflederer: Thank you.