Team Coordination, Data Sharing Help Prioritize Value in Cardio-Renal-Metabolic Care

Am J Manag Care. 2025;31(Spec. No. 10):SP737-SP739. https://doi.org/10.37765/ajmc.2025.89802

Just as the heart and the kidneys rely on one another to keep the body functioning optimally, so do all members of the care team responsible for ensuring value-based, high-quality care for patients with cardio-renal-metabolic syndrome, according to speakers at an Institute for Value-Based Medicine event in Scottsdale, Arizona, on August 26, 2025. The event, held by The American Journal of Managed Care in partnership with Banner Health, featured faculty from the health system as well as cardiologists, nephrologists, primary care physicians (PCPs), payer representatives, and more.

Event chair Ed Clarke, MD, vice president and chief medical officer at Banner Health Plans & Networks, explained that Banner’s extensive reach across clinically integrated networks, wholly owned plans, and care provision can make it difficult to coordinate care across large and partly rural markets such as Arizona’s. “If you haven’t checked, we’re all aging and getting older, and when this happens, we end up with things like CHF [congestive heart failure], CKD [chronic kidney disease], diabetes, obesity—these are really epidemic everywhere. There are many in the audience who will be up here on the panel whose mission is to figure out how to help these patients better connect the care among all the teams that are helping them, to have better outcomes and better lives.”

One speaker on such a mission is Bryan Becker, MD, MMM, CPE, FACP, FNKF, FAAPL, chief medical officer of Duo Health, a growing kidney care–focused medical group. He described a patient anecdote that exemplifies Duo’s approach: An older, frail patient with multiple chronic conditions wanted to stop receiving dialysis, which triggered a home visit that revealed his depression, anxiety, and chronic pain. The care team was able to connect him with counseling and antidepressants, and the patient received daily follow-ups that motivated him to continue dialysis.

“The care of patients with kidney disease has to encompass…that global perspective of chronic conditions, and that includes even how you’re going to take care of that patient from a psychiatric standpoint,” Becker said.

He described CKD as a quiet but enormous problem in terms of patient outcomes and dollars spent. New data from McKinsey & Company show the significant savings that could be achieved if value-based care levers such as site-of-care selection, complication prevention, and treatment optimization were employed to their fullest in the nephrology field: Approximately 25% to 27% of the total cost of care is addressable, with potential annual savings of up to $40 billion.1

Policy changes in the past decade, such as the Advancing American Kidney Health initiative,2 have attempted to improve kidney care, Becker said, but many focused on optimizing late-stage care, such as transplants, rather than slowing or preventing disease upstream. Now, novel therapeutics have the power to change the kidney disease trajectory, and there is more of a focus on care models that include psychosocial care and communicate across a patient’s entire medical neighborhood.

“We recognize that taking [patient] care to different places, not expecting patients to come into a clinic, has greater benefits, both for efficacy and for engagement,” Becker said of Duo’s approach. “We’re not going to be perfect in identifying everything that a patient [needs], but in bringing this model together with the acknowledgement that those patients have a primary care base, we can support and do things for that [PCP] and with the nephrologist or another specialist…we actually bring a different way [to support] care for these patients in our health care system.”

The next speaker also discussed ways to support and treat patients with cardio-renal-metabolic disease, but from a cardiology perspective, given the tightly connected and interdependent nature of the heart and the kidneys. Manoj Rawal, MD, FACC, a cardiologist with Cardiac Solutions, explained the difference between cardiorenal syndrome (when heart failure leads to kidney dysfunction) and renocardiac syndrome (vice versa) and showed a slide of the complex interplay of organ systems and physiologic events that characterize these states.

According to Rawal, the mechanisms explaining cardiorenal syndrome are reduced cardiac output or venous congestion, which are often addressed with loop diuretics. Other therapeutic options, such as cardiac resynchronization therapy, may also improve the function of both organ systems,3 but Rawal noted that the choice of intervention in an acute care setting is not the only predictor of improvement.

“Salt restriction and fluid restriction [are] key. I always tell my patients, ‘You can outeat or outdrink any amount of diuretic I give you,’ ” Rawal said, noting that patients who don’t adhere to these guidelines often end up back in the hospital.

These readmissions not only affect patient quality of life but also carry a sizable economic burden, which is why Rawal expressed his support for integrated care models in which multidisciplinary teams work together and share data in real time. These models are gaining steam amid rising chronic disease burden, cost pressures, and the growing popularity of value-based payment models, but Rawal noted the data-sharing component as a potential pitfall. In a world with multiple electronic health record (EHR) platforms that cannot communicate with one another and many providers still dependent on the fax machine, insight between PCPs and specialists is often limited, with pharmacists even further out of the loop.

“We have to figure out a way for information to flow seamlessly without borders to actually be useful,” Rawal said. “Care coordination in terms of dedicated care coordinators also is needed. They will help patients navigate these visits and ensure follow-ups. And the most important thing is patients have to be engaged—all these programs must incentivize patients so they can meet us halfway.”

“We’ve got our work cut out for us,” Clarke acknowledged, reflecting on the speakers’ presentations on the importance of acting upstream and preventing the cascade of cardiorenal dysfunction.

To further explore the opportunities to prioritize value, Becker and Rawal were joined by experts from across the health care ecosystem for a panel moderated by Chuck Lehn, president of Banner Health Network. Those representing the primary care perspective agreed that coordination is a real challenge when caring for patients with symptoms spanning organ systems. When a PCP is not physically at the hospital with a patient, “notes go back and forth sometimes, not all the time, and the biggest challenge is that a PCP is working with incomplete information. It’s really a best guess,” said Mark Stephan, MD, MBA, Arizona medical director of Equality Health.

Kevin Ellis, DO, chief medical officer of the Medicare Advantage plan and dual-eligible special needs plan at Banner Health, added that it’s often unclear what each provider’s role is—for instance, which clinician orders laboratory tests—and that can lead to everyone assuming a next step is someone else’s responsibility. That can be enormously confusing to the patient, especially when language barriers are involved, said Sheena Sharma, MD, medical director of Banner University Health Plan. She noted that after-visit summaries aim to solve this problem but often get discarded or left behind when a patient leaves the office or hospital. Still, “that’s as far as we’ve come, because there’s no universal EHR,” she said.

What does work well is when PCPs in clinically integrated networks have care compacts that lay out guidelines, responsibilities, and steps to expect during the specialty referral process, Ellis said. That way, “each one knows their role…and the patient is not left in the lurch. It creates more of a seamless integration between primary care and specialty care,” he said.

Audience member Karen Gonsalves-Wetherell, MD, added that VillageMD, where she is the national medical officer for the western region, uses an integrated approach in its high-touch programs, aiming to reach patients at high risk before they decompensate. “It’s the team approach—our care managers, our social workers, our APPs [advanced practice providers]—being available all the time to try to prevent what we can,” she said.

The panel also touched on the transformative impact of novel therapeutics on cardiorenal care. Data showing the impact of sodium-glucose cotransporter 2 inhibitors on slowing loss of kidney function and preventing hospitalizations have led to a “fundamental shift in therapy,” Becker said, such that prescribing these agents, glucagon-like peptide 1 receptor agonists, and mineralocorticoid receptor agonists has become a next-generation quality measure of appropriate treatment.

Panelist Manjunath Kottalgi, MD, a nephrologist at Desert Kidney Associates, emphasized the need to appropriately prescribe these new therapeutics while avoiding risky polypharmacy. He also called for stepped-up efforts to “engage, educate, and empower the patients themselves.”

The speakers agreed on the importance of investing in primary care, activating patients to manage their health, and incentivizing each clinical team member to prevent downstream cardiorenal events. “Plans need to recognize and have payer reimbursement for these medical programs or AI [artificial intelligence] models so that we are preventing admissions,” Rawal said. “We all recognize that CHF admissions and readmissions are super expensive, but what are we doing to actually reduce them?”

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

References

1. Kunte A, Patel N, Abou-Atme Z, Flynn A. Specialty risk: the next frontier of value-based care. McKinsey. July 22, 2025. Accessed August 27, 2025. https://www.mckinsey.com/industries/healthcare/our-insights/specialty-risk-the-next-frontier-of-value-based-care
2. Rosenberg J. HHS unveils 5 new payment models to transform kidney disease care. AJMC. July 10, 2019. https://www.ajmc.com/view/hhs-unveils-5-new-payment-models-to-transform-kidney-disease-care
3. Adelstein EC, Shalaby A, Saba S. Response to cardiac resynchronization therapy in patients with heart failure and renal insufficiency. Pacing Clin Electrophysiol. 2010;33(7):850-859. doi:10.1111/j.1540-8159.2010.02705.x