Health Plan Strategies for Better CKD Care: Moving Beyond Vendors

<p>help the primary care, get them to the right oncologist, get them to the right um imaging studies, get them, you know, if there's issues with prior, help all of that. [Music] Hello everyone and welcome to the American Journal of Healthcare Strategy. Uh today we're joined by a really special guest who's going to be talking about more of these really innovative population health approaches, intelligent approaches to managing uh CKD. Um Dr.</p> <p>Beth Malco, can you please introduce yourself and just give us a little bit of background? Sure. Um as you indicated, my name is Beth Malco. I uh am a family practitioner by training. Uh before that I was an engineer for a little while. Um I was in private practice uh in Connecticut and also worked in a rural health clinic um in uh in uh in Vermont.</p> <p>Uh and then I have spent um a very long time uh getting on to 30 years in a variety of roles uh in both health plans uh and working for payer organizations uh in really to help make sure that members patients are getting um affordable quality healthcare.</p> <p>Why did you make that kind of change throughout your career uh from engineering to medicine and then with even within medicine as you mentioned you've worked uh for a few different uh kind of angles right you haven't just been at one angle you've done a few why is that what have what has drew you to all of those things well aside from the fact that I obviously get bored pretty easily um re realistically I I really always wanted to do medicine um my uh master's degree is actually in environmental engineering ing.</p> <p>So very much about health um and and making sure that we weren't polluting the air and water um to keep people healthy. So it was actually a fairly natural um connection to go back into medicine and and in medicine in family practice. It was interesting because I kind of thought I left engineering behind. But what I found was that I was really interested in system solutions and I enjoyed I I did get to save some lives and that was wonderful.</p> <p>But I looked at healthcare and I looked at how it was functioning in the US and really fill in like, huh, you know, I could actually bring some of those project and process skill sets to play um in more of a systemsbased solution really helping to improve overall health care and and and how insurers were delivering that health care. And so um I was actually in a large group practice. We started taking risk as a practice group in the 90s in Medicaid, maybe my lifetime claim to fame.</p> <p>We actually um were successful and and really did make some money and also did some incredibly innovative things that helped our patients really get better care and better outcomes and that kind of got me hooked. Um, I tried going back full-time to practice because I really missed practice and then realized no that those larger system solutions were much more interesting to me and probably the better use of of my talents and skills. And it's been quite a ride.</p> <p>It's been uh really interesting and exciting and done some really fun and and innovative and I think valuable things for for members and patients across the different states that I've worked in.</p> <p>I really appreciate what you're saying about the systems kind of thinking process when it comes to health care because with primary care with healthy individuals um you know middle-aged and younger they usually there's not as much friction that occurs but when you start adding things on to it and whether that's SDO whether that's a complex condition usually the two go hand in hand if we've discussed on past episodes you begin to really put strain on the existing system and you need to develop new ones.</p> <p>Why is that the case? Why, you know, and where are you seeing that the most where people need that complex system to really carry them through? What what conditions are you really talking about? Well, you know, it's really any any condition that is life-threatening that is really impactful to your life. So, you know, realistically, the system, the health care system isn't designed to to make the connections that need to be made. And primary care physicians are actually uniquely suited for that.</p> <p>And it's really a great deal of the strength that we bring to the table is knowing what's going on in the whole patient, right? So, a lot of young women only see their OB/GYN, which is okay, I guess, but it really is very helpful to have somebody who can make sure you're getting your flu shot and your tetanus shot is up to date. And, you know, even young people do get horrible diseases, right?</p> <p>They get cancers, they get pneumonas, and you really need somebody who is on top of the whole picture and and really can make that family connection as well. So in in my practice experience, I literally had four generations in my practice that that I was taking care of and really could understand where some of those friction points were coming from in a family to a member. You know, her diabetes was worse or she wasn't managing her COPD because her 15year-old daughter just got pregnant.</p> <p>She was so stressed out she couldn't think straight. Right? So that ability that primary care brings to the table to really make those connections is enormously helpful. And if you look internationally at all of the first world countries, they are very very much primary care-based um and and really unfortunately most of all of them have significantly better health outcomes overall when you look at a population than the United States does.</p> <p>So I'm a little bit bullish about the importance of primary care and how you make those connections, how you deal with the social determinance of health, how you deal with connecting. So you just get diagnosed with renal disease and now you're going to see the nefologist and you know, god forbid it progresses and now you're going to need to have a graft put in and and now you're going to need to see a nutritionist because you need to change your diet.</p> <p>I mean there's all and like how does that all work? How does that happen? How do you keep all the pieces and parts together? So, what if you also have heart disease and how do we make sure that the cardiologist isn't prescribing something that's going to interfere with your renal disease? And so, I think it's critically important to have that quarterback um that that the PCP really is, especially both in people with complex illnesses and just in older people in general.</p> <p>I just read a a a heard I guess a statistic yesterday that something like 89% of older patients, people who are on Medicare over 65 are taking at least one medication and and many of them are taking many many more than one medications and so uh and seeing multiple specialists and it it it is just a scenario that is ripe for problems if you don't have that quarterbacking in place. So sorry I get a little bullish on primary care. No, no.</p> <p>And I think what we see too is health systems invest a good amount in making their primary care work and making it so that uh you know they're kind of a central um kind of repository for information and for data. But payers don't often have this, right? So you know you you invest in your EMR, your EHR, they implement AI solutions at the primary care level which helps the physician, but payers often don't have that.</p> <p>and payers a lot of times can't tell what's happening from one specialist to another specialist to primary care. And that's very difficult. But at the same time, it seems like the complex conditions in specialty care is costing payers 10, 20fold what they're spending on primary care. And so I guess it's concerning that you're saying that the root of a lot of the fixes is primary care, but we don't see our payers who are responsible for paying for our healthcare really spending in that area.</p> <p>Why is that? And and what do you where do you think we go from here? And I'm not sure that's entirely true. Actually, most health plans have been um continually yearover-year increasing the reimbursement rate to primary care while holding specialty rates flat. Now, does that make up for the baseline difference? No. And that actually comes out of MedPAC um because MedPAC sets the CMS rates and they definitely um are very specialty based and focused in the rates.</p> <p>But but again, MedPAC 2 over a number of years has been holding the specialty rates flat and increasing the primary care rates. So I think um health plans do absolutely recognize the value of primary care.</p> <p>Many of them have entered into um risk-based arrangements and they can be anything from simply upside uh rewards for improving the the health of the member both in terms of quality and in terms of outcomes um but also into full-blown risk arrangements where um a a primary care group is getting a percent of premium risk and and many of the more sophisticated health plans and this is widely used in California. We're starting to see much more of it in Florida.</p> <p>In fact, in South Florida, you see a lot of it. Massachusetts has had risk-based arrangements for years. Um, and providing the primary care physicians the tools to to actually help this. And and you know, it's interesting that you say, you know, that and I talked about the the the split about care is happening over here and care is happening over here.</p> <p>In fact, frankly, the only the only one who knows what's going on is the health plan because we see all the claims and it's an area that um health plans are are building provider portals that are really helping to create some of that information flow um back to the primary care physicians.</p> <p>And so um you know both on that I frequently say to to primary care physicians you know the patient comes in their hypertension is still not controlled and so you switch them to another um anti-hypertensive you probably should have called me first because I could have told you whether or not they were actually taking their anti-hypertensive because I can see how often.</p> <p>So let's say you've prescribed an anti-hypertensive twice a day and I see that they're only filling that antihypertensive every two months. Well, duh. They're only taking it once a day. So, I actually know as a health plan more about who the patients are seeing and where they've been admitted.</p> <p>So, you know, if you're admitted, you're traveling internationally, you're traveling across the country, you're admitted to a hospital, that's probably never going to get back to the primary care physician, but it gets back to me um as a health plan. So in fact I think many of the health plans are becoming much more cognizant of the capabilities they have to actually share that kind of information with primary care physicians. Is it perfect? No.</p> <p>But but I I think it it really is important to understand that health plans acknowledge that they have more information than anybody realizes that they have and that increasingly we need to be able to share that. Now, there are some federal rules that make sharing certain information um problematic. So, you can't share behavioral health information, you can't share um substance abuse information, and you can't share HIV information.</p> <p>Um and it it it's a challenge and I think there's a lot of people working on that.</p> <p>So it will never be perfect um from a health plan perspective but but I do think that the health plans are are actively engaged in sharing more information and I actually think that's one of the things that that health map um has been very effective in doing is actually engaging primary care physicians um about how to help manage renal disease and how to make sure that they're making those connections with the nefologist.</p> <p>So I think that there are other scenarios like that but it's actually one of the things that I found unique about um about Healthmap is lots of um clinical partners or vendors work with primary care physicians on diabetes on this or that but on really actually being working on that connection between the nefologist and the primary care physician you don't see that very often and I think that's really one of the strengths that that um that Healthmap has brought to the table.</p> <p>I think it's been very successful for them and was actually one of the selling points for me to work with them. And that's what I wanted to ask was you've laid a good foundation. So the the data is definitely on the health plan side with accomplishing this this issue. the funding has, as you mentioned, started to to turn and so the attitude is there, but there is still this this struggle and we've seen a big rise in point solutions with AI, right? Everybody offers a point solution for everything.</p> <p>Even talking in our past episodes, I was talking to to both Tom and um Eric and I've said, uh, you know, you could have a thousand point solutions uh for everything that that's offered. And so that kind of makes me ask this question, which is when we're selecting a vendor as a health plan, how do you select the right vendor and not get tied up in a single point solution or get tied up in something that's not actually going to work and and help your patients? How do you make that judgment? Yeah.</p> <p>So, I there's a there's a number of things I think about when I look at um a potential vendor. And in fact, I think the language I use is really important because I really don't I'm not interested in working with vendors. I'm interested in working with clinical partners. And I think that's really important for a number of reasons. So when I look for a vendor or a clinical partner, I'm looking for someone who brings a solution that is a health plan I'm never going to find by myself.</p> <p>a health plan is not going to be able to unless you're United or your or your elephants and even they um are unlikely to have a staff of oncologists or a staff of nefologists or a staff of cardiologists. And if you think about each of those, they'd have to have, you know, like 20 specialists and have to have, you know, a staff of multiple ones. That's not realistic. That's not going to happen.</p> <p>So, we're looking for clinical partners who bring something to the table that as a health plan, especially a small health plan, but even a medium-size or large health plan, even a jumbo, um, I can't really bring to the table. I am looking for a partner. I am looking for someone who is in some way, shape or form going to have some skin in the game around outcomes. So the old model of working with vendors was very much where you contracted with the vendor.</p> <p>They promised that they would do X, Y, and Z and save you X number of dollars and you signed a contract and in the contract you put some SLAs's and the SLAs's were how quickly they'd answer the phone, how many calls were abandoned, how many members they might engage with. But there were no KPIs that said these are the outcomes we're expecting. We're going to see a decrease in ER utilization. We're going to see a decrease in hospitalization. We're going to see an increase in quality scores. Right?</p> <p>So, it was very transactional and not based on a collaborative partnership and an outcome. And so, I think that that model has shifted dramatically nationally.</p> <p>um every place I've been in the last 15 years probably it's really been about let's develop that partnership and you know I'm not necessarily saying that a clinical partner has to be at full risk although there are partnerships like that that are wonderful but at the very least those fees that you're charging to you know to create outcome X Y and Z have to be at risk to show that you are in fact achieving those outcomes and that we have KPIs that are really measuring those outcomes because you know I can tell you about vendor after vendor where wait a minute you said you were going to reduce our our utilization of cat scans and I'm not seeing it I'm not seeing any reduction at all and then you know you start to get into the story about why that is I'm like no I just want to see the reduction right that was the idea here and so you know to reiterate I want to see a capability that I as a health plan do not have.</p> <p>I want a clinical partner. I don't want a vendor. And that clinical partner really has to have um some skin in the game. Um it has to be measured on the things that matter, not Yes, they have to answer the phone on time. Like that's they're still in there. I'm not getting rid of those, right? Um and that there has to be a sense of collaboration, right?</p> <p>Um, so in my past experience, I I go back to a sleep vendor that I we were actually the first ones to use this sleep vendor and um it was just all heck was breaking loose in in Massachusetts at the time and I would have this sleep lab director and she had my number and she called me weekly and this is happening that's happening the other thing is happening and the leader of that they really were a clinical partner would come back within an hour and give me answers to every single one of those issues and say, "By the way, I already picked up the phone and spoke to Dr.</p> <p>So and so and we're going to move this forward." I I that's what you're looking for.</p> <p>If you really need to have a partner who and again I go back to that word partner who is going to be collaborative who's going to work with you who is going to acknowledge that everything isn't going to go swimmingly that you know at an implementation health plans make mistake partners make mistake that we're going to work through those mistakes that things are going to arise that were not anticipated and we're not never going to see the hand we're always going to have that collaborative discussion.</p> <p>So those those three things are absolutely critical to me. And then of course I need to have good reference checks where I'm able to see to talk to a health plan that's similar in size and shape to me um that has worked with this clinical partner and has seen that collaboration has seen the kind of outcomes that that I'm looking to see. So I think it's a very different approach um that you have to take in terms of finding someone. I think two other things play a role and you hit on the first one.</p> <p>Um, are you working with that vendor in another place or with another? So, you know, if you have a vendor who you're doing end of life with and they also have an oncology program, wow, why would you bring in a different vendor to do oncology? Like, you would want to connect those. And hey, if that vendor also has genetic testing, that could be really helpful, right?</p> <p>So, so yes, there's no question that minimizing, you know, multiple point solutions, especially all around a single disease state is cuckoo crazy, right? You don't want to do that. Um, so you really if you have a good clinical partner and they have another service that they can offer and and that they have had good results in, yes, that is going to be very important in your thinking about vendor selection. not definitive but very important and experience in your geography.</p> <p>Um, you know, you've worked in one state, you've worked in one state. Every state is different. Some remarkably different, some, you know, some are pretty, you know, run-of-the-mill. There are some real outliers out there. And understanding how Medicaid works in that state, understanding, you know, the different CMS regions have different LCDs, local coverage determinations.</p> <p>the fact that they've worked in your geography successfully at work your providers like they've already worked with your providers under another health plan those that is important again not definitive but important in making a vendor selection or especially in in finding a clinical partner. So based on what you said, that sounds really great, right? It makes a lot of sense, but I feel like it requires an executive level of input. Um, and really a clinical level of input from the health plan.</p> <p>Um, and what I mean is that when I'm just choosing a vendor, you know, like a software as a service vendor that a lot of vendors utilize, that goes through my vendor management team, I probably never see it. Usually, it goes up through the CFO's office. It's usually using requisition forms, you know, because it's not a partner, right? Like you're saying this isn't really a person or organization. It's more of a thing that you're buying.</p> <p>But in this case, you're saying it's a clinical partner and you need that involvement. One of the push backs that I might get from, you know, the seauite in that is that sounds like a lot of work. I don't want to deal with having to get involved in my vendor selection. Do you think you could maybe share why doing that extra work up front is actually way more valuable for you as an executive at a health plan?</p> <p>Yeah, I mean look, hands down that you know the the chief medical officer is part of the seauite and any clinical vendor decisionmaking ultimately really has to have a strong thumbrint of the chief medical officer and um generally the chief medical officer is running your total medical expense committee or cost of care committee.</p> <p>Most places call it a total medical expense committee and and that construct around the chief medical officer being responsible for cost of care, being responsible for quality of care, i.e. affordable quality health care. That's their job, right?</p> <p>and their job is to do all the vetting to run that through the total medical expense committee to make sure that all of those uh bits and bites are are ticked and tied so that when it comes up to to the CFO to the CEO to say hey we're ready to go forward with this contract and here's why that you know you're hiring a CMO who is data savvy who can run a total a medical expense committee who can bring you a package frankly tied in a bow that is is you know not a lot of work on the part of the CFO or the CEO but it's like oh well that makes a ton of sense you basically told me you're bringing a partner who you know if I can go to a to a CEO and say okay so this vendor is guaranteeing with their fees this outcome or taking a capitated rate that's going to increase over time and it it's sort of free money and it's sort of a give me for our members.</p> <p>It can only help our members. You don't get a lot of push back. Um I think that the CFOs in particular, but CEOs as well, are kind of done with vendors on the clinical side, right? And so that idea of wait, you're bringing me another vendor who I'm going to pay a fee and they tell me they're going to do something and then it doesn't happen like like we need to learn. And so my response is, yep, I agree with you completely.</p> <p>I would never hire a vendor and I would never hire a vendor under those circumstances. This is completely different. And it does take some work on the CMO's part to really get the CEO and the CFO to understand this very very different dynamic, right? It really is, you know, I I I hate that paradigm shift, right? I hate, you know, sea change, paradigm shift. We've all heard it so many times we cringe, but it is it is a fundamental paradigm shift that says we are not hiring another vendor.</p> <p>we're hiring a clinical partner who is in as deep as we are in getting the outcomes that we need. And by the way, these outcomes really matter to the member and they matter to our bottom line. Um, and I I I actually um, yeah, the first couple of times you have that conversation, it's hard, but once the CMO has shown that, yeah, that's what they're doing and the vendors they're bringing in are delivering it, it doesn't become a difficult conversation at all anymore.</p> <p>So, you just have to do it that get over the hump of of getting Absolutely. Right. Yeah. Nothing succeeds like success, right? So, and as a CMO after you've implemented this a couple times, are you saving time down the line? Because right now, you know, some CMOs a lot of times it falls under the chief data officer or tech officer. They're putting out fires constantly when it comes to vendors. I'm assuming that goes away when you start using partners or at least not as much. Yeah, not as much.</p> <p>I don't want to say goes away because you know um there so I I I love that you're talking about the data piece because I think that is a huge issue and it is a huge hump that has to be overcome every single time and the advice that now I'm working as a consultant I give to to my my my health plans and that I used myself is here's the data set we have that you will be getting. You'll need to figure out how to use this data set.</p> <p>We are not going to spend hours, days, weeks creating the data set that that you want. Here's our data set. If you want to work with us, you're going to have to figure out how to use it. And it's remarkable how often that works. Um because you're saying, look, I can't be creating a completely different data set for every single partner. And and it's not even the partner, right?</p> <p>when you're when you've sent an RFI out and you're you know you're you're comparing three or four potential clinical partners, you can't be set creating three or four different data sets like that isn't going to work. So the first time the IT team hears you say that they're like oh wait I like her let's chat some more about how this is going to work right. Um and it does work.</p> <p>Um and you know I I do think it's it's very important to learn from each implementation because with each implementation there is some it glitch. It's a given. Um it turned out that we didn't send this over or and it it frequently is a glitch on the health plan side. It can also be a glitch on the partner side. Um, but but really if you've already picked a partner who you know is going to be collaborative, then you can get over those glitches.</p> <p>And you know, the more you do this, I've been doing this for 30 years. The more you can see right away, oh, stop. We're not we're not going to have this fight. We're going to figure this out. Here's what happened. We understand what happened. Let's figure out how we can fix it jointly. and and if the partner isn't willing to have that conversation and be part of the fix, we won't renew with that partner. Or if it's early in the stage, we'll stop the implementation and end the contract there.</p> <p>So, I think it's it's experience and and expertise in working with the IT team and understanding that this isn't a pure clinical solution. And in order for the clinical solution to work, you have to have accurate um interfaces and and exchanges of data or else it's not going to work. And that's as important to this as anything else. So your vendor management team is wonderful.</p> <p>You need one, but they they have to really work intimately with the clinical team and they have to be connected with the the IT team. And I was very fortunate um in uh at when I was at Florida Blue um the the team that was actually supporting as project managers our TME committee actually came out of the IT shop. So a lot of those barriers we didn't have to deal with because they they they spoke it. Right. Right. And so I think it really is important to learn to speak it pretty early on.</p> <p>I think that's important. It's a it's a really interesting thing.</p> <p>I did not even think of because one of a friend I met at HIMS his whole firm does that for health systems they uh move the data alter the data and prepare it for their vendors and that's what his whole company does is just the changing around of that um so I think it's it's interesting the hidden costs that could be maybe removed and I'm thinking you know legal costs litigation costs all kinds of things that people experience um I I want to shift gears for a minute though and ask a question based on your primary care experience.</p> <p>And that's because we've spoken with specialists on how it improves specialists. We've spoken with, you know, individuals on how it can improve their kind of personal lives. But from a primary care perspective, how does a partner with a health plan like Health Maps benefit you as the provider providing the services? Well, your initial response is, yeah, no, not interested. Thanks anyway.</p> <p>Because the last thing you need is the last thing is you need is somebody else telling you how to practice medicine, right? And that that is the the normal the normal response, right? And so it really again it comes back to that partnership. It is the CMO or the provider relations team who is reaching out to both the clinical leadership and the business leadership of the practices.</p> <p>And you start with your larger practices and work your way down to say, "Hey, you know that renal disease is a huge issue." And I as a clinician can say, "Hey, primary care doctor, primary care doc, you know, you know, we're not very good at at nefology. None of us are. It's really hard. And it's something that, you know, we struggle with. Most of us don't have a ton of CKD patients. We don't have a ton of ESRD patients.</p> <p>Um, and what this clinical partner is going to really want to do is probably speak with you, CMO, speak with you, um, you know, business officer, office manager, practice manager, and really figure out how we can get in there and get get you guys situated such that you're identifying members with CKD early in the process. You're getting them off to nefologist early in the process. that you know we're helping you that knowing that we're there.</p> <p>We're case managing the members, you know, if the member is getting worse, if they don't like their nefologist and they need a new one, that this partner is going to be there to help you and and ideally you start with your at risk PCP groups. And by the way, if we can reduce these costs, this is going to help you enormously. And I will say that 90% of the time that works really well. um getting having that conversation with a onesie twoosy practice is probably not going to happen.</p> <p>They they don't have the time in it and it's just not going to happen. And so you do the best you send them a letter. You let them know you're available. Provider relations is stopping in for something else. They're going to mention it. They're going to address it.</p> <p>But, you know, it's really in increasingly so many practices or large group practices that being able to connect with with both a clinical leader and a business leader at the practice allows you to really, you know, make the case and then be available. So, the clinical partners being a pain, you know, that that clinical leader is going to call me and say, "Yeah, remember that clinical partner you talked to me about? Yeah, I got it. I'll fix it.</p> <p>We'll work it out." Um, but but you know, you have to be available to be able to do that and to make those connections. You can't send a letter and say, "Oh, by the way, you know, this new partner is going to call you and they're going to tell you how to how to practice medicine for your renal disease patients." Yeah. No, that doesn't work. You have to do the work. Yeah. That's so important too as systems. I just think about the resource for the system perspective.</p> <p>You know, when when people onboard vendors to the payer, I feel like sometimes vendors are not treated as how they're going to affect, you know, they they care about their patients, but they don't always care about the providers in their network, right? And I don't think that's their fault. I think it's because it's another stakeholder, a more complicated stakeholder.</p> <p>But when you're using the partnership approach, it seems like you are taking into account as the CMO of a health plan, how it's going to impact the providers of the community, not just the patients. Well, but you know it at the end of the day, health plans while we do we believe very strongly that our case management really helps to improve the health of our members and that our quality initiatives really help.</p> <p>It is the provider who was taking care of the patient and our job is not to get in the way of that and to the extent that we can to provide them resources and support in order to do so. And it is in those very complicated patients. Um, especially patients who, you know, again, you've got an ESRD patient, they may very well, they're at higher risk for all sorts of complications. They're more likely to, you know, you you got to be very careful about their immunizations.</p> <p>You have to be careful about the other medications that they're on. You have to make sure they understand their diet. And it's a lot. And it's really a lot for a primary care physician and to be able to say, "We're here. We're case managing the member. We're reinforcing these messages. We're going to help be that communication between you and the the nefologist. We're here for you. That can actually be enormously helpful.</p> <p>Now, as a health plan, if you were to provide that for the cardiology patients and the renewal patients and the D Yeah. No, that's not going to work, right? So, you can't be having 12 vendors who are calling a PCP practice and saying, "Hey, we can help you with this." Right. Um, yeah, that that doesn't make any sense. But I think nefology and oncology in particular are kind of two outliers. Once a patient is diagnosed with cancer, they go off to the oncologist.</p> <p>And yes, they're going to show up in the primary care office, but the the oncology care is happening at the oncology location with the oncologist. The and and half the time they get admitted for a a problem. They have febri neutropenia. They get admitted to the hospital. The primary care doesn't even know about it. Mhm. The same thing with nefrology.</p> <p>I mean, at the end of the day, there's I don't think there's any question that getting a patient to a nephrologist early in their CKD course can be enormously helpful because there are so many bits and pieces that have to be sorted. The meds have to be sorted, the diet has to be sorted. um the management of the complicating conditions like hypertension and diabetes have to be really pulled together and working closely with the nefologist is is critically important.</p> <p>God forbid they move on to ESRD again, they disappear into the into the nefrology space. And so I I think I think of those two disease states as being such that yes, for oncology care, you know, we can help the primary care physician early when the patient is just being diagnosed. Help the primary care, get them to the right oncologist, get them to the right um imaging studies, get them, you know, if there's issues with prior, help all of that.</p> <p>um once they're with the oncologist, we can continue to case management them. When they're done with the oncologist and they come back to the PCP, we can step in and help again. But again, not necessarily working as closely with the PCP. Nephology again sits out there alone. You know, the the the data is pretty clear. A lot of early CKD, especially, you know, two and three where it really starts to matter, isn't even identified by primary care physicians. I had a similar situation personally.</p> <p>I I don't have renal disease at all, but um I was taking a drug that was dehydrating the heck out of me and I said, "Hey, you know, my GFR isn't really No, I'm a doc, right? My GFR isn't really where I should be. Should I see a nefologist?" Oh, no. You know, just just drink more water. And you know, eight months later when we retested and I was I looked to be in an acute renal failure like you and it was just dehydration.</p> <p>But but the point is that um you know I think as primary care physicians there are so many things we're worrying about that catching that early CKD and then changing the medications and worrying about protein loads and and worrying about you know just the the you know controlling the diabetes and the hypertension much more aggressively in a patient who's showing signs of early CKD. That's a lot. It really is.</p> <p>And so, you know, that support to say, "Hey, you know, nefology is really hard and we're here to help you. If you don't want our help, that's fine. We're we're still going to help the member. We're still going to work with the nefologist, but if you want our help, we're here." That was a very compelling um argument to me as a primary care physician. Yeah.</p> <p>especially for a a high friction, high complexity, uh requiring much more education, you know, uh in that specialized area just to be able to to treat um the disease. I think I think that's difficult for health systems to manage as well from a a health system perspective is how do you move patients from primary care to these specialties? I know in neurology it's been a big discussion. Can we try to treat migraine patients in primary care more um before shifting them?</p> <p>I think that's an example of an area where it's easier it's easier to do that and then you have the really high complex ones like you mentioned oncology and and nephrology can't be done. And so I I see this as a resource for primary care but also for the health system and and that's excellent. Uh thank you Dr. Melco for coming on and discussing this from the perspective of a primary care physician, a health plan executive, and uh an engineer as well.</p> <p>We heard quite a bit about systems engineering uh in there, and I'm I'm reading a a book on it right now, so I picked up some terms. Uh so, thank you for this really in-depth conversation, and I hope we can have you on again. Oh, I'd be delighted. This lovely chatting with</p>