Clinical Performance Supports Organized Value-Based Care


Figure 1 | Visualization of the value equation

Visualization of the value equation, percent of ESCO population vs calcimimetrics per member per month

Within a quality vs. cost grid, or effectiveness vs. efficiency—which is the terminology preferred by many payors—the prescriber’s goal in a value-based arena is to be in the upper-right quadrant where quality is high and costs are low; it would be best to avoid the left lower quadrant where quality is low and costs are high. This data visualization tool permits participants—in this case, the calcimimetic prescriber—to drill down to further identify both positive and negative outliers. The view in Figure 1 includes over 45,000 ESKD patients in 23 separate markets. Each market is represented by a bubble, and the relative size of the bubble reflects the population within a specific ESCO. But each market can be viewed independently, reestablishing the origin of the grid such that individual practices in a specific market or individual dialysis facilities can be compared with their peers. Providing population health views of quality and cost data to prescribers leads to actionable insights for them, which ultimately improves clinical performance.

Optimal clinical performance within value-based arrangements brings many advantages to patients. When clinical performance excels within a value-based program, that performance often translates into financial improvement. These financial “wins” create a funding mechanism for additional clinical interventions, resulting in a virtuous cycle that benefits patients. Consider FHP’s experience with transition-of-care (TOC) visits. During the early years of the ESCO program, a nephrologist billing Medicare for a monthly capitation payment could not submit a claim for a transitional care management service (TCM). The TCM service is designed to improve the transition from the inpatient venue of care to the outpatient venue of care. Believing such a service was vital to care coordination, FHP designed an ESKD-specific TOC template and inserted it into the nephrology provider’s workflow.

When TOC visits are completed following discharge from the hospital, the ESCO pays the nephrology practice for delivering that service. In the company’s experience, patients receiving the TOC visit had a lower 30-day readmission rate (Figure 2).

Figure 2 | Thirty-day readmission rates in ESKD patients by TOC visit status

Graph of thirty-day readmission rates in ESKD patients by TOC visit status per month

In a transactional fee-for-service environment, the expense of delivering TOC to ESKD patients is not covered. But when assuming risk for the total cost of care, the calculus changes. When pay is for value rather than volume, a funding mechanism emerges. The financial savings for avoided hospital stays no longer accrues to the payor alone, but to the value-based arrangement participants, permitting the investment in clinical interventions that may be out of reach in a fee-for-service environment.

The beginning of a patient’s journey with ESKD provides another example of the importance of clinical performance. The transition from CKD to ESKD is fraught with perils that emerge when care is fragmented. Coordinating care during this transition can have a tremendous impact on clinical performance. FMCNA’s Renal Care Coordinator program, in collaboration with physician practices, has not only improved the transition to ESKD for patients with late-stage CKD, but also had a positive impact on optimal starts, in-center treatment adherence, and the total cost of care within the first six months of starting dialysis (Figure 3).

Figure 3 | Impact of the Renal Care Coordinator program

Graphic of impact of the Renal Care Coordinator program


FMCNA believes it begins with the nephrology medical staff. Imagine a physician-centric organization that combines the depth and breadth of the Fresenius Medical Care VBC experience with literally hundreds of talented nephrologists from around the country. In December 2019, Fresenius Medical Care, along with more than 650 nephrologists across the United States, formed a joint venture partnership called InterWell Health. This venture combines the expertise of a diverse and preeminent group of nephrology practices with the experience of FMCNA to advance value-based contracting models such as those discussed above that are attractive to medical staff, payors, and patients by driving better clinical outcomes at lower costs. The network will deliver population health management services across the full continuum of CKD, transplant, ESKD, and conservative care.

InterWell Health will establish best practices and set expectations to drive optimal clinical performance across a variety of valuebased arrangements. Importantly, InterWell Health’s value extends far beyond the walls of the company, because the organization will develop a national high-performing renal network, allowing all nephrologists to have an opportunity to successfully participate in value-based arrangements. InterWell Health addresses the need to have a more physician-centric model to manage the total cost of care.

The shift to VBC is well under way. Fresenius Medical Care’s early ESCO and payor experience have established a strong foundation, highlighting the enterprise’s ability to succeed in VBC. As renal-related value-based arrangements expand to include renal transplant and CKD, optimizing clinical performance will become even more important to the medical staff, patients, and the company. InterWell Health is the next step in the VBC journey, collaboratively helping Fresenius Medical Care build on early success through population health management and optimal clinical performance.

Meet The Experts


Kim Sonnen head shot

Director and President, InterWell Health

Terry Ketchersid head shot

Chief Medical Officer, Integrated Care Group, Fresenius Medical Care North America; Co-Chief Medical Officer, InterWell Health

Karen Gledhill head shot

Director and Executive Vice President, InterWell Health; Senior Vice President and General Counsel, Fresenius Medical Care


  1. What is value-based healthcare? NEJM Catalyst, Jan. 1, 2017. https://catalyst.nejm. org/doi/full/10.1056/CAT.17.0558.
  2. Centers for Medicare and Medicaid Services. ESRD Disease Management Demonstration. Last updated May 1, 2015. https://innovation.cms.gov/Medicare-Demonstrations/ESRD-Disease-Management-Demonstration.html.

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