Hey everyone, this is Kate Stanton, co-host of the Pulse podcast. In this episode, I sat down with Dr. Bassem Mikhail, SVP of the Clinical Enterprise at Somatis. Started in 2016 by Dr. Ikenna Okayzi, Somatis partners with clinicians, health plans, health systems, and multidisciplinary community-based care teams to improve health, quality of life, and cost of care for patients with kidney disease. Somatis employs over 1,450 team members and serves more than 150,000 patients across 36 states. Dr. Mikhail and I discuss the vital role that kidneys play in maintaining health, the issues that arise from diseased kidneys, and how these challenges translate into per patient costs that are 10 times higher on average than those for patients without kidney disease. The traditional model for treating patients with chronic kidney disease, CKD, and end-stage kidney disease, EFKD, and how Somatis’ model realigns incentives to focus on integrated, preventative, and patient-centric care. Why the federal government, CMS, and CMMI have prioritized investments in kidney care and what we’ve learned from their initiatives and care model tests. And finally, clinical innovations that make Dr. Mikhail optimistic about the future for patients living with kidney disease. Dr. Mikhail, thanks so much for joining me on The Pulse. How are you doing today? Hi, Kate. I’m doing well. Thank you so much for having me on The Pulse. It’s great to be with you. So we have a tradition of asking our guest, an icebreaker, to kick off our episodes. So when you were a kid, what did you want to be when you grew up? Yeah, I knew from an early age, Kate, that I wanted to grow up to become a physician. Part of that for me was an interest and fascination with learning how our body works. And then a big part of it for me also was my father, who’s a physician, seeing and hearing about how he took care of patients and his passion for that as I was growing up had a big influence on me and on shaping what I wanted to pursue in my own career. Tell me about your path to becoming a nephrologist specifically. Yeah, absolutely. So there’s a few things that drew me to nephrology. First was the intellectual complexity. As I studied renal physiology when I was in medical school, I was really drawn to the incredible complexity and how intricately our kidneys function. The manner by which our kidneys maintain homeostasis in our bodies is really elegant. And I was drawn to understanding such nuanced physiology as I was learning that in medical school. And then as I went on to my clinical years, I really loved the practice of nephrology for a few reasons. One, because the kidneys play such a central role in managing our overall health related to all of our other organ systems, treating patients with kidney disease requires a very holistic view for each patient. One of my clinical mentors, as I was training, told me to be an excellent nephrologist, you have to also be an excellent internist. I really enjoyed general medicine and being able to still incorporate the principles of general medicine, even within my specialty practice of nephrology. So I really liked that aspect. The other thing that really drew me to nephrology is the wide spectrum of disease acuity that we manage in nephrology. So we see patients who are very, very sick with kidney failure in the intensive care unit. We see patients on general medical floors in the hospital. And then, of course, take care of patients in the outpatient clinic or in the dialysis clinic setting. And I like being able to practice across that full spectrum of clinical acuity and also really importantly, to maintain longitudinal relationships with my patients, whether I was seeing them in clinic outside the hospital, or I was seeing them when they were hospitalized. The last thing also I’d mention is my dad is a nephrologist as well. And so I really enjoyed getting to sort of follow in his footsteps and share that experience with him. So you did your residency and fellowship at MGH and now you’re at Somatis. So why was Somatis the next move for you? So starting when I was in college, Kate, and really going on through the rest of my medical training, I had always been thinking about how I could have broad impact on as many patients as I could. When I was an undergraduate, I studied economics. I had an interest in health policy when I was in college prior to going to medical school. Ultimately, I learned after spending a summer working in health policy that that probably wasn’t quite the right fit for me at that point in my career. But I decided to pursue an MBA for management training when I was in medical school, because I knew that the macroeconomic trend was going to force a change in how health care is delivered in a way that had to be done at a lower cost. And so I wanted to be equipped as a physician to be able to drive that change in care delivery organizations. And my experience at HBS was really pivotal for me to understand how to lead and drive change in organizations. As I went throughout the rest of my training and as I thought about this change in nephrology specifically, kidney care had really started to undergo a major transformation in the way that care was being delivered to patients with kidney disease. And Somatis, through our co-founder and CEO, Dr. Akeno Kaze, had really created the truly value-based kidney care space back in 2016. So I got connected with Akeno and I saw his vision for revolutionizing the delivery of kidney care to focus on delaying disease progression and recentering care to be where it should be, which is patient-centered and integrated. For me, joining the Somatis team provided an opportunity for me to help to lead this transformation in kidney care and help many, many thousands of patients across the country to improve their outcomes and their quality of life. And I’m really fortunate in my role. I’m still able to practice nephrology and see patients even while I work alongside my colleagues at Somatis to set the strategies to really bring better care and support for patients living with chronic kidney disease and end-stage kidney disease across the country. You started to allude to this, but I’d love to get a brief overview of Somatis as well as your role in the organization and your key responsibilities. Yeah. So Somatis was founded back in 2016, and the goal and the mission is to revolutionize kidney care and become the world’s best provider of integrated kidney care. And so at Somatis, we partner with nephrologists, primary care physicians, with health plans, with health systems all across the U.S. to provide integrated care for patients with or at risk of kidney disease. We’re operating in about 36 states currently, caring for over 150,000 patients across the U.S. And our focus, Kate, is not being a fee-for-service dialysis provider, but instead being a value-based kidney care provider. So to do that, we leverage care teams, multidisciplinary care teams across the country who are able to meet with patients in their home. We leverage a really rich technology solution, and then we’ll work really closely with our physician partners to serve as an extension of their practice to transform how kidney care is delivered for them away from the sort of reactive nature of in-center dialysis, where a lot of kidney care had historically been delivered, to instead being very proactive, focusing on preventative care, delaying disease progression, and improving quality of life for patients to bend the curve of disease morbidity and really improve patient outcomes. So that’s kind of a little bit about Somatis, and I’m sure I’ll talk more about that as we go on. My role at Somatis, I serve as the Senior Vice President of the Clinical Enterprise at Somatis, so I help to lead our efforts and I work closely with our clinical teams, our technology teams, our physician engagement teams to build and deliver our clinical model and care to all of our patients. So that entails working to innovate and advance our clinical model over time as we partner with physicians across the country and to improve patient outcomes together. And then in addition to working with our health plan partners, I think one other thing I’d highlight is we continue to develop value-based partnerships with physician and physician practices across the country. In the traditional fee-for-service system, as physicians, we had become really incentivized to practice volume-based medicine. So the system incentivized the number of encounters we have with patients reacting to problems rather than upfront time to prioritize preventative care. A large part of what we focus on at Somatis is realigning those incentives for physicians to where they should be, which is the same as the patient, so that when the patient does well, the providers and the care delivery system does well also. Thanks for sharing that. And we’ll dig into many aspects of the overview you just shared. To get our listeners sort of all on the same page about the status quo for kidney care, so can you share what the experience looks like for an average patient with chronic kidney disease, CKD, today and as the condition progresses? Yeah, it’s a great question. So to give folks an understanding of what it’s like to live with kidney disease or chronic kidney disease, let me first give just a little bit of context or background about how our kidneys function, because understanding what the kidneys do when they normally function helps folks to understand, I think, what happens when there’s disease in the kidneys. So most of us, Kate, are born with two kidneys, and our kidneys are really very incredible organs. I could probably wax much longer than your listeners are interested in about kidney physiology, but just as a brief highlight, so that the kidneys weigh really less than a pound combined, and they play an absolutely critical role in maintaining our normal physiology. There’s an old adage that we say in nephrology that many people think that what the kidneys produces urine, but really what the kidneys produces homeostasis. So each kidney is made up of about a million nephrons, which are the basic functional unit in the kidney. And those small filters work together to allow the kidney to perform all the major jobs that it has to keep us healthy. So our kidneys will clean and filter our blood of things like acids and potassium and toxins. They’ll regulate our fluid levels in our body to make sure we don’t become too dehydrated or have too much fluid in our bodies. They regulate our blood pressure. They balance a lot of the electrolytes in our body, which enable normal functioning for many of our other organs, like our brain or our hearts. And to give you a perspective on kind of the importance of the kidneys, even though they together make up only about maybe 0.5% or so of our body weight, they receive more than 25% of the heart’s output every minute as a reflection of the important work that they do. That’s kind of what normal kidney functioning is like. When the kidneys are diseased, they’re not able to do these basic functions of the kidney. And so patients can develop symptoms related to any of those issues. So when the kidneys aren’t able to regulate our fluid levels, patients can accumulate fluid and they can develop swelling in their legs, fluid in the lungs or difficulty breathing. When the kidneys are not able to clean and filter the blood, the levels of electrolytes can become too high and that can cause things like abnormal heart rhythms and build up of toxins in the blood can lead to confusion and cognitive impairment. We grade kidney disease in five general stages ranging from CKD 1 through CKD stage 5. The later stages, CKD stages 4 and 5 are the more severe forms of kidney disease. And then the term end stage kidney disease or ESKD, that refers to when patients are no longer able to do the job of cleaning our blood. And so patients would need a form of kidney replacement therapy. So something like a kidney transplant or dialysis treatments in order to survive. One of the challenging aspects of CKD and the patient experience in CKD is that most patients do not really develop significant symptoms until the disease has progressed to its later stages. So that’s why early diagnosis and preventative care is essential. But it’s harder to do in chronic kidney disease because patients don’t experience symptoms earlier on. To give you a sense of this from the macro perspective. So across the country, the CDC’s estimate is that over 37 million U.S. adults are estimated to have some form of kidney disease and about 40 percent of those, even when they’re in the advanced stages, are not aware of their kidney disease. And so that leads to a lot of downstream problems for patients as they go throughout the disease stage. Can you explain a little bit more about the transplant process, how often they happen and why we might not be seeing as many patients getting transplants as we’d like, as well as some of the benefits of that potentially over dialysis? Yeah, absolutely. So there’s two major forms of kidney transplant. So there’s living kidney transplantation as well as deceased kidney transplantation. And living kidney transplantation is really the best form of kidney replacement therapy. It usually will allow patients to receive their transplant before they have to start on dialysis, presuming that they have a donor. And then there’s also deceased kidney transplantation, which is the more common form of kidney transplantation, where a deceased organ becomes available through the organ sharing network and then patients are placed on a waitlist for that and then are able to receive a kidney transplant when an organ is found for them. Kidney transplant really is the best form of kidney replacement therapy for end-stage kidney disease. If a patient is already on dialysis, it will allow them to come off of dialysis, assuming the kidney transplant goes well. It allows them to live a life that’s much closer to how they lived prior to when they had kidney disease in terms of diet and nutrition and the other aspects of patient life, which is really important. Now, there’s a number of barriers to kidney transplantation in terms of the availability of organs, the process by which that occurs. There’s a mismatch between supply and demand in terms of the number of patients who need kidney transplants versus the number of organs that are available. And there’s a lot of work going on to try to improve all aspects, really, of that process. I want to give our listeners a sense of how these care models that we’ve been discussing translate into health care dollars. And about 1% of Medicare patients have ESKD, yet this 1% accounts for 7% of spending. And I believe the average Medicare patient with ESRD costs the system around $90,000. So can you shed some light into the reasons for this really very high spend? Yeah, of course. And you’re right. So Medicare PMPY for ESKD is about 10 times or more higher than the average Medicare patient without kidney disease, which is closer to probably about $9,000 or so with some variability. And I think one thing to highlight also, Kate, is so that cost gap applies not just to ESKD, but also to CKD as well. So the Medicare PMPY is about $27,000 or so for CKD as a whole, which even that is about three times higher than the average non-CKD Medicare patient. And there’s a few reasons for this. And it’s important to understand these. And I think you’re right. So Medicare has identified this as a significant challenge for them to work on, given the very high and disproportionate cost that CKD and ESKD patients place for Medicare. So across the board in patients’ care journeys, when you look at Medicare data, patients who have CKD compared to those who do not have kidney disease, they have much higher mortality, much higher morbidity. If you look at CKD patients, the hospitalization rates are three or four times higher in late stage CKD than they are in patients who don’t have CKD. Readmission rates to the hospital are about 50% higher. ER, emergency department utilization, is about two times as high as patients who don’t have CKD. And the reason for that is that though comorbidities are similar, the presence of kidney disease really complicates management, even of common chronic conditions, because our kidneys regulate so many functions in our body, from blood pressure to blood sugar. And when the kidneys are diseased, it makes the management of many of those conditions more complicated. So for example, high blood pressure or hypertension is very prevalent in the US overall, and it’s prevalent among patients with CKD. But successfully controlling blood pressure in the setting of advanced CKD is more challenging. Might need different medications or different approaches or different doses. The same could be true or said of something like congestive heart failure, for instance. Management of fluid overload is a lot more complicated in patients who have advanced kidney disease than in patients who don’t. And that clinical complexity, especially in the context of the fragmentation in our healthcare delivery system, translates into higher utilization, higher hospitalization rates, higher costs associated with that. And the same is true, but certainly much more pronounced for ESKD patients who have even higher hospitalization and readmission utilization as a function of their advanced state of illness. And then you layer on top of that, of course, the actual cost of providing the dialysis treatment itself. So going to the center and having that treatment three days a week. For the vast majority of patients who are on in-center dialysis, there’s a significant cost to providing that treatment that factors in, of course, to the very high healthcare expenditure in the setting of ESKD. I think another potentially interesting dynamic related to this high cost element is the fact that patients with ESKD are eligible for Medicare. So other than ALS, it’s the only condition where people with a specific clinical condition are eligible for Medicare. So I’m curious about what types of unique dynamics do you think this creates for patients, providers, and other stakeholders in the system, kind of that EKSD care kind of functions within a single-payer system? I think there’s a few things to say there. So one, we’re seeing some changes in that in terms of CMS’s commitment to innovation and payment models. CMS has launched a new sort of payment model to apply for patients with late-stage CKD as well as ESKD to incentivize things like delaying disease progression, which is good. But I think, you know, historically, Kate, that’s been part of the challenge that we’re struggling with in kidney care, that the focus previously across the healthcare system has been on the volume of in-center or fee-for-service dialysis that’s provided instead of having an incentive to move upstream, to educate patients earlier in the disease, and to delay disease progression to try to reduce the number of patients who progress to need dialysis. And of course, the cost for ESKD, as we described, is much higher than it is for CKD. And so the system would benefit from incentivizing delaying disease progression to reduce the number of patients who need ESKD. But historically, up until recently, those incentives have not really been there. Let’s transition to chatting more about how Somatis is focused on reducing the likelihood of disease progression as well as lowering the cost of care, as you were saying, moving more towards a value-based paradigm from the historical fee-for-service one that really dominated not only the sector of healthcare, but really the system at large. I’d love to hear some details about how Somatis’ care model is impacting a few areas that are central to the experience of patients with ESKD. So I would love to start with home care, as it’s one that we’ve alluded to a few times. So how is Somatis really focused on not only transitioning patients to receive dialysis in the home, but then also supporting them in that care plan once they start? Yeah, of course. I think, as we described, because at Somatis, we take risk for patients’ clinical quality outcomes as well as their total cost of care. So we will only do well when the patient does well. And then we’ve really carefully designed our clinical model to be able to help patients do well and to improve their outcomes. A big part of that is home care, certainly. So our clinical model is both very individualized to each patient, but we take a very holistic view as well. Core to providing good kidney care is providing good whole patient care. So that means we focus on addressing not only the kidney-specific issues, whether that’s CKD or ESKD issues, but also comorbidity-specific issues like diabetes or high blood pressure or cardiovascular disease, as well as issues related to barriers in access to care and issues related to social determinants of health and in psychosocial care needs. And we’ve been very deliberate to build our model of care across all of those areas so that we can meet each patient where they are and address comprehensively what their needs are. Executing on that, we’ve built a really robust technology platform. So we’ll incorporate data from a multitude of sources, and then we’ll use best-in-class predictive analytics to help us predict or identify which patients are at high risk of utilization events, like going to the hospital or going to the ER, which patients are at very high risk of disease progression. And we believe a lot in the value of care delivery at home. And so we’ve hired multidisciplinary field-based care teams across the country. So those are comprised of nurse care managers, patient health advocates or community health workers, social workers, dieticians, nurse practitioners, physicians who are able to meet with patients in their homes, identify their care needs, and then really serve as an extension of their physician’s practice in the home. And I think in clinic, one of the things I learned, Kate, is that I would see patients in clinic, but it would be very hard for me to know what was going on in their home environment, which was often a major driver of barriers in care or barriers in access. And so our teams will really kind of serve as physicians’ eyes and ears in the home to identify issues that will be very hard for us in clinic to identify. A loose rug in the hallway between the bedroom and the bathroom that’s a fall risk, disordered medications or looking at the fridge to see a patient’s understanding about their nutrition plan. Those are all areas which are really important to focus on for the patient comprehensively, but you need to have a presence in the home to be able to do that. And so we built our model to do that. And I think the other part in your question was, how do we delay disease progression? That’s really a major primary focus for us is how can we most optimally engage patients earlier on in their disease stage and CKD to delay their disease progression. So for the earlier stage CKD patients, we take a really strong focus on primary care. So we’ll identify who are the subset of even the early stage patients who have risk factors for rapid kidney disease progression and need to be prioritized to have an earlier evaluation by a nephrologist. Remember, for many early stage patients, they may have no symptoms. And so we’ll work closely with the patient to educate them, work with their PCP on the importance of getting them plugged into appropriate or early nephrology care. Even while we’ll work with them to focus on many of their chronic comorbid conditions. Now, about half of our patients have diabetes, over 90% have high blood pressure, about half will have cardiovascular disease or congestive heart failure. So as a platform, we actually spend a lot of time managing a host of chronic conditions, which track together with kidney disease. And we do that for a few reasons. So one, it’s good for the patient as we manage their other chronic comorbidities that’ll improve their health. But secondly, it’s core to being able to be effective to delay disease progression. About two thirds or so incident ESKD cases in the US each year are due to diabetes and hypertension. And so managing those two chronic conditions alone goes a really long way to delaying disease progression. I think the other big part of that is medications. So we’ll work closely to make sure that patients have access to and are on the right medications to delay their disease progression. Something that struck me as you were speaking was just how many types of different care providers, many who are not employed by Somatis, need to be involved in a patient’s care. So that could be their PCP, the nephrologist, mental health providers. As you mentioned, diabetes is a main comorbidity for kidney disease. So potentially endocrinologists or cardiologists. So really a whole host of providers. So if you could dig into a bit more how Somatis incorporates providers in the market external to your organization, into your care model, realizing that Somatis is in risk-based contracts, but these other providers might be external to them. I’d love to hear more about how you partner with these providers over time in order to reach successful outcomes for your patients. Yeah, absolutely. It’s something we think a lot about. We really feel that the patient-physician relationship is paramount. Because of our incentive structure, because we take risk for patients’ outcomes, their clinical outcomes, as well as their total cost of care outcomes, we’re able to work with our physician partners to realign that incentive and restore it for them so that the physician’s incentives becomes aligned again with the patient’s incentives. So we’ve structured our model to be an extension of our partner physicians, especially our nephrologist partners who are really the central driver of care for late-stage CKD and ESKD patients. I think you touched on a really important point, Kate, which is that patients with CKD and ESKD rarely have kind of just that as their clinical problem. The prevalence of comorbid conditions is very high in this patient population. And so though nephrologists tend to be the central driver of care for late-stage patients with kidney disease, it is really important to factor into the model the need to collaborate with other physicians. So with PCPs, of course, but also with some of the other specialists you mentioned. So we’ll work a lot with endocrinologists for diabetes care, with cardiologists for cardiovascular care, as well as other specialists as well. And being able to do that in a way that gives the patient a cohesive experience is really important. If you think about this from the patient’s perspective, the patient may be juggling multiple appointments with different specialists with different medication lists and different prescriptions coming from each appointment. It can be very overwhelming and very difficult to navigate the care process as a patient in this system. And that’s even if you have a really full understanding of everything that’s going on, which, of course, not all patients do. And we can support practice operations as well. And so our teams will go, because they’re all local, they’ll spend time in the patient’s home. They can spend time in the practice’s offices if that’s helpful. Nephrologists and physicians are the center of care delivery, and we really work to come alongside them to enable them to deliver better care for the patients as they have always wanted to deliver. And to also have access to share in the economic value and in the savings that they generate when they’re able to do that. And that’s really the beauty of value-based care in this way, because our incentives are aligned with the patient’s outcome. We’re able to then align the physician’s incentives with that of the patient so that all parties, the payer, the provider, the patient, us, we’re all working towards the same objective, which is keeping the patient healthy and having an improved outcome for them. That segues well into my next question, and we’ve sort of been dancing around this a bit or mentioning it, but not diving into it. That is around how CMMI has been exploring a number of ways to better address CKD and ESKD, because as you put it, due to the really high spend for patients with these conditions, CMS has identified this as an area that needs greater investment and testing in order to ideally improve quality and outcomes and reduce costs. So, over the years, they’ve proposed the comprehensive end-stage renal disease care model, CDC, as well as some additional models in more recent years, including KCC, which is aimed at helping providers take on risk and deliver care, such as transplants that decelerate disease progression. Seems really aligned with the type of work that Somatis is investing in. To start, can you summarize what we’ve learned from these tests to date? I think one of the important things that we’ve seen is that CMS has really rightly recognized the need to incentivize delaying disease progression. There’s a few major developments that have come from CMS in this space. Let’s say one of the first in recent years was back in 2019 with the Advancing American Kidney Health Executive Order. So, that laid out a few core principles and goals related to slowing the number of patients who progress to ESKD, increasing the proportion of ESKD patients who receive either home dialysis treatment or a kidney transplant, and then finally, increasing the number of kidneys that are available through transplant. And so, some of the more recent payment models, the reference of KCC, like the kidney care choices and all of the options within that are essentially a reflection of the goals that were laid out in the Advancing American Kidney Health Initiative. And these new payment models essentially allow for a direct contracting model with CMS that has stemmed from this. I think for many nephrologists, these KCC models are a really big step forward into diving into value-based care. This has happened in primary care previously. In the last 15 or 20 years, we’ve seen a huge amount of innovation and progress in primary care around providers and PCPs taking risk for their patient panels and being able to align incentives together with the patients. So, we’re really happy to see these kind of regulatory tailwinds bolstering the commitment that CMS has and expanding that into value-based kidney care as well. Definitely seems like we’re going through a time when there’s a lot of attention on an investment in kidney care for the reasons that we discussed. So, I too am excited to see how it continues to evolve. A follow-up question I have about this that I think relates to most healthcare companies, but especially one where there is so much investment and attention from the government. I’m wondering how you think it impacts or doesn’t impact business operations and planning as a business when operating in a space that is really highly dependent on policy and potential changes? It’s a great question. I think we’ve seen things evolve over time in the last few years. So, part of it is certainly the regulatory component, and I think we’ve seen a lot of tailwinds actually in that. We started this back in 2016 before many of these events occurred, the Advanced American Kidney Initiative or the CKCC model. But we’re excited to see CMS invest in this as well. But I think to our earlier discussion on the 21st Century Cures Act, even apart from the CMS investment in these models, because ESKD patients are now eligible for Medicare Advantage plans, we’ve seen a lot of demand and a lot of interest from health plans, so Medicare Advantage plans, who are increasingly caring for patients with ESKD to find a solution to help them manage their total cost of care, because the cost and the complexity of the patients is the same, right? Whether that is a patient who’s on Medicare fee-for-service, and that’s accruing to Medicare, or whether that’s an ESKD patient who selects to go on a Medicare Advantage plan, and then that cost is accruing to the Medicare Advantage plan, they will still need a plan or a solution to be able to manage the complexity of these patients to reduce their cost of care and to improve their outcomes. I think that’s an important component as well. We’ve seen a lot of growth in that over the last few years, and I expect to see that continue to grow as well. I think you mentioned how that impacts business operations at Somatis and how we’re thinking about that. I think for us, it’s a very exciting time. As a nephrologist, certainly I’m really optimistic, and I think we’ve seen a lot of change in the last few years. We’re, I think, going to see even more change in the coming years, and we’re really excited at Somatis to be leading that change. Even just in the time that I’ve been at Somatis, I’ve seen really rapid growth to drive this transformation across the country. And so that’s really been exciting to be part of that, and I think we expect to see a lot more growth as we plan for that in the next several years. We’re actually planning on doing what will likely be our last private round of financing starting in April. And so we have an internal team working on an optimal process for that with a select group of investors. If any of your listeners or anyone wants more information, they can, of course, feel free to contact me on that offline, and I’ll plug them into the team at Somatis. But I think there’s a lot of more great work to be done, and we’re really excited, I think, and delighted to be able to drive this improvement in care for even more patients in the coming years. Three other areas that I want to discuss that I see as really closely tied to kidney care, but potentially less directly than some of the other areas that we’ve discussed are caregiver support, social determinants of health, as well as reducing inequity. Across these areas, where do you see the most exciting improvements happening for patients with kidney disease? Yeah, those are all such important points. One of the major areas for us that we have prioritized and are focusing on is on health equity and understanding the impact of social determinants of health on disparities and outcomes. I think kidney care has been marked by very significant disparities and outcomes over the last several decades. CKD disproportionately impacts BIPOC patient populations, so by the CDC’s estimate, African American patients make up about 13 percent of the U.S. population, but over a third of dialysis patients. CKD is much more prevalent among African American patients and Hispanic American patients as well. If you think about it, the first-year mortality rate for ESKD is about 20 percent. The five-year survival is roughly about 40 percent or so. These disparities in kidney health, those statistics are often cited because they’re from the CDC, but if you put them in the context of the mortality that I just described that’s associated with ESKD, it becomes clear, I think, that these disparities in kidney health have massive implications for vulnerable patient populations, and so there’s urgency in having a solution to address some of these disparities and outcomes for vulnerable patients. We see that across a number of different areas. In recent years, I mentioned new therapeutic classes like SGLT2 inhibitors, which can delay disease progression, which is a really important factor and a really important thing to address for ESKD, and they have dramatic benefit in improving mortality, but if patients can’t or don’t actually get access to these medications, then we won’t see the needed benefit that is needed to improve health equity, and so this applies to many aspects in social determinants of health. It impacts medication affordability. It impacts even something as simple as transportation. I’ll give you an example of something that seems very straightforward, but actually is a really very real barrier for patients, which is transportation. We see this all the time in our patient population, so CKD patients, they’re on a number of chronic medications. They’ll need, for example, diuretics, which are water pills to help them manage their fluid levels, and something as simple as if you don’t have a ride to get to the pharmacy to pick up your diuretic prescription and you’re not able to take it, then for the patient, their fluid levels will build up, and they may end up having a very expensive hospitalization for fluid overload. Similarly, for a dialysis patient, when dialysis patients miss even one treatment, they’re at significantly higher risk of having an inpatient hospitalization, but getting to and from their treatment needs a ride, right? They need a transportation source to be able to get to the treatment, and so in our traditional environment, there really is no incentives, and as physicians, we don’t have any resources to try and intervene up front on something as simple as a ride, but at Samanas, because we’re at risk for the total cost of care for the patient, we are able to do things like help patients address transportation gaps so that a $15 car ride to and from the pharmacy or to and from a dialysis center may help a patient be healthy and stay healthy at home and avoid a very costly hospitalization. Yeah, I think your example about transportation while it might seem micro is indeed a really good kind of summary of why value-based models, especially for this population, make a ton of sense. So bringing together all the things that we have discussed, what are the three main ways you expect the standard of care for CKD and ESKD to evolve in the next five years? A few things that come to mind are, number one, increased attention and prioritization of screening and early identification of CKD. So we’ll partner with organizations like the National Kidney Foundation or others to be able to increase patient and community awareness, education, and understanding of chronic kidney disease, and I think that’s a really important lever in our aim of trying to delay disease progression. A really important part of that is patient understanding and patient awareness that they have kidney disease, what kidney disease is, and the importance of managing kidney disease early, even when it’s asymptomatic. You know, it’s always hard, right? If you’re not experiencing symptoms or something doesn’t seem to be a pressing problem today, it’s harder to focus on preventative care. But helping patients understand the importance of that and working with primary care doctors and nephrologists and other physicians to be able to prioritize that, I think, is a really important component. A second one is on novel treatments and therapeutics. So that’s something that is new in kidney care in the last five or 10 years, and it’s very welcome, I think, the innovation that we’ve seen. We’re very excited about and very keen on focusing on improving adoption of medications which delay disease progression, and that’s a major area of focus for us with our physician partners, primary care doctors, nephrologists, et cetera. And access to having these novel interventions, so new therapeutics, new medications, new treatment classes, I think are going to be a very important component of the story of how we’re able to delay disease progression in the U.S. And then the third one, I would say, I think is what we started some of the discussion with around kidney transplants, around home dialysis. For those patients who do reach end-stage kidney disease, increased innovation around being able to do dialysis at home to remove barriers and making that process easier for patients to do at home, as well as on improving some of the barriers in kidney transplantation, I think are going to be an important part of the story of kidney care. So I think all three of those areas are probably, I think, the major areas that we’ll see evolve in the coming years. Wrapping up our conversation, I just have one final question, and that’s more going back to your personal experience as a clinician who made the transition to working at a startup, at least for now. What advice do you have for clinicians who are considering joining a care delivery startup? I’m very optimistic about the innovation in care delivery and in value-based care that’s occurring across health care overall. There’s innovation in biotech. There’s innovation in health IT and technology and care delivery. And I think it’s really important for these organizations to have clinicians who are guiding the work that they do to ensure that the service or the product or whatever it is that the startup is focused on is something that will ultimately solve an unmet need, which is present in the delivery of care to patients. That’s something that at Somatis, I think we focus on every day. Everyone in the organization, from our clinical teams, our operations teams, our technology teams, everybody has that same central focus, which is how can what I’m working on, this project or this initiative or this work, improve care for one of our Somatis patients. And I think that’s something that’s core to the operating system or the blood or the culture at Somatis, I should say, is everyone is focused on how to improve care for patients. One piece of advice I think that I would give for clinicians who are thinking about making a transition to a care delivery startup of some kind would be to continue to practice medicine and see patients. That’s something I think that’s very important to me. I think many of us who take on these roles like to do so because we’re trying to have a broad impact on health care and on patients, whether that is through being an investigator in an academic organization or through public policy or through an organization like Somatis. But I think continuing to see patients is important for us as clinicians. It helps keep us grounded, I think, in the reason why we’re doing this work in the first place, which is to improve patient care. And patient care happens one patient at a time. I think that perspective is important to keep in mind, even as we work to improve some of the systems and incentives and other challenges to be able to improve broad care across the system. I love that and feel like it’s a good note to end on. So, Dr. Mikhail, thank you so much for joining me on The Pulse. I really enjoyed our conversation. I truly learned a ton about CKD and ESKD and kidney care at large, both sort of at the micro organ level, but also at a systemic level. So thank you so much for your time. Oh, thank you, Kate. I really enjoyed our conversation as well. It’s been a pleasure. So thanks so much for having me on the podcast.

Dr. Mikhail’s early fascination with medicine, inspired by his father’s career, highlights the importance of following one’s passion from a young age, which can shape future career choices.

The intellectual challenge in nephrology drew Dr. Mikhail to the field. Embracing complexity in any profession can lead to deeper understanding and fulfillment.

The need for a holistic view in treating kidney disease emphasizes the importance of considering the whole patient—physical, emotional, and social factors—when providing care.

Dr. Mikhail’s transition to Somatis to help drive change in kidney care illustrates the value of innovative thinking and adaptability in addressing healthcare challenges.

The necessity of working with a variety of healthcare providers to achieve better patient outcomes underscores the importance of collaboration in any field, especially in complex systems like healthcare.

The shift from fee-for-service to value-based care models represents a significant change in healthcare, emphasizing the need for systems that prioritize patient outcomes over the volume of services provided.

The discussion on chronic kidney disease stresses the importance of early diagnosis and preventive care, a lesson that applies across many health conditions.

Recognizing and addressing social determinants of health—such as transportation and medication access—can significantly impact patient outcomes, highlighting the need for a comprehensive approach to healthcare.

Dr. Mikhail’s advice to clinicians considering startup roles emphasizes the importance of continuing to practice medicine to stay grounded and informed about patient needs.

The focus on improving care for patients at Somatis illustrates that the best innovations in healthcare come from understanding and addressing the real needs of patients.

Dr. Bassem Mikhail’s journey began with a childhood fascination for medicine, heavily influenced by his father, a physician, who demonstrated passion for patient care, igniting Dr. Mikhail’s desire to become a doctor.

During medical school, Dr. Mikhail discovered his interest in nephrology, drawn by the intricate physiology of kidneys and their central role in maintaining overall health, which fueled his passion for the specialty.

He embraced the holistic view required in nephrology, emphasizing the importance of understanding the interplay between kidney health and other organ systems, which aligned with his enjoyment of general medicine.

Dr. Mikhail valued the opportunity to manage a wide spectrum of kidney disease acuity, from critically ill patients to outpatient care, fostering long-term relationships with patients across various settings.

While pursuing his medical training, Dr. Mikhail’s interest in health policy led him to study economics and ultimately pursue an MBA to equip himself with the skills to drive change in healthcare delivery.

Recognizing the macroeconomic trends in healthcare, he sought to be part of the transformation in nephrology, particularly in how care was delivered to patients with kidney disease.

In 2016, Dr. Mikhail connected with Somatis, co-founded by Dr. Ikenna Okayzi, attracted by their vision to revolutionize kidney care through a patient-centered, integrated approach focused on delaying disease progression.

At Somatis, Dr. Mikhail plays a pivotal role in leading the transformation of kidney care, emphasizing a shift from fee-for-service models to value-based care, enhancing patient outcomes and quality of life.

Somatis collaborates with nephrologists, primary care physicians, and health systems across 36 states, serving over 150,000 patients, showcasing a commitment to integrated care for those with or at risk of kidney disease.

Dr. Mikhail expresses optimism about clinical innovations in kidney care, highlighting the potential for improved patient outcomes and quality of life through the initiatives and strategies implemented at Somatis.

The speaker recognized the limitations of traditional in-center dialysis, which was reactive and often led to poor patient outcomes in chronic kidney disease (CKD) management.

To address these issues, they established multidisciplinary care teams across the country, enabling healthcare providers to meet patients in their homes and deliver more personalized care.

The integration of advanced technology solutions was emphasized as a means to enhance patient monitoring and care delivery, ensuring a proactive approach to kidney health.

They forged strong partnerships with physician practices, aiming to transform the care model from volume-based medicine to a value-based system that prioritizes preventative care.

The initiative focused on realigning incentives for healthcare providers, ensuring that both patient and provider successes are linked, thus fostering a collaborative environment for better health outcomes.

The speaker highlighted the importance of early diagnosis and preventative care in CKD, noting that many patients remain unaware of their condition until it reaches advanced stages.

They provided insights into kidney physiology, illustrating the critical roles kidneys play in overall health, which helps frame the urgency of effective kidney care.

The discussion included the complexities of kidney transplantation, including the differences between living and deceased donor transplants, and the need for increased awareness and accessibility.

The speaker articulated the advantages of kidney transplants, emphasizing that they allow patients to regain a lifestyle closer to normalcy compared to the constraints of dialysis.

Throughout their journey, they remain dedicated to innovating and advancing their clinical model, continuously seeking ways to improve patient outcomes in kidney care.

The podcast begins by highlighting the significant barriers to kidney transplantation, emphasizing the mismatch between the number of patients needing transplants and the available organs.

The discussion reveals that approximately 1% of Medicare patients have End-Stage Kidney Disease (ESKD), yet this group accounts for a staggering 7% of Medicare spending, illustrating the financial burden on the healthcare system.

It is noted that the average costs for Medicare patients with ESKD are around $90,000, which is substantially higher than the average Medicare patient without kidney disease, leading to questions about the reasons behind these high expenditures.

The conversation identifies that patients with Chronic Kidney Disease (CKD) experience much higher mortality and morbidity, leading to increased hospitalization and emergency room visits, which further drives up costs.

The complexities in managing common chronic conditions like hypertension and congestive heart failure in patients with kidney disease are discussed, highlighting the additional challenges these patients face compared to those without CKD.

The high costs associated with providing dialysis treatment, particularly for patients undergoing in-center dialysis three times a week, are acknowledged as significant contributors to the overall healthcare expenditure for ESKD.

The podcast points out that ESKD patients are uniquely eligible for Medicare, creating dynamics that affect patients, providers, and stakeholders within a single-payer system.

The conversation shifts to recent changes by the Centers for Medicare & Medicaid Services (CMS) aimed at incentivizing the delay of disease progression and improving care models for CKD and ESKD patients.

Somatis is introduced as a company focusing on reducing disease progression and costs, emphasizing a transition from a fee-for-service model to a value-based care approach.

Somatis’ care model is described as individualized and holistic, addressing not only kidney-specific issues but also comorbidities and social determinants of health, ensuring comprehensive support for patients in their care journey.

The journey begins with the establishment of a robust technology platform that integrates data from various sources, enabling predictive analytics to identify patients at high risk for hospitalizations and disease progression.

A strong conviction emerges around the value of delivering care in patients’ homes, leading to the recruitment of multidisciplinary field-based care teams, including nurses, social workers, and dieticians.

Insights from clinical experiences reveal that home environments significantly impact patient care. This realization drives the need for care teams to assess patients’ living conditions and identify potential barriers to health.

A strategic shift occurs towards engaging patients early in their disease stages, particularly for chronic kidney disease (CKD), emphasizing education and timely referrals to nephrologists.

Recognizing the prevalence of comorbidities like diabetes and hypertension among CKD patients, the care model expands to include management of these conditions, crucial for delaying disease progression.

A commitment to patient-centered care leads to the integration of various external healthcare providers, including primary care physicians and specialists, ensuring a cohesive treatment experience for patients.

The organization adopts a risk-based contract model that aligns incentives among patients, physicians, and payers, fostering collaboration aimed at improved health outcomes.

Efforts are made to simplify the navigation of care for patients juggling multiple specialists, emphasizing coordination and communication to alleviate stress and confusion.

The model positions nephrologists as central figures in patient care, providing them with support and resources to enhance their practice and deliver the quality of care they aspire to provide.

Ultimately, the overarching belief in value-based care culminates in a shared objective among all stakeholders—maintaining patient health and improving outcomes through collaborative efforts.

The journey began with the acknowledgment of the high costs associated with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), prompting the Centers for Medicare & Medicaid Services (CMS) to explore innovative care models.

The pivotal moment came with the Executive Order that set clear goals: slowing ESKD progression, increasing home dialysis and transplant rates, and boosting kidney availability for transplants.

The Kidney Care Choices (KCC) model emerged as a significant step towards value-based care, allowing nephrologists to take on risk and align incentives with patient outcomes, reflecting the goals of the Advancing American Kidney Health Initiative.

The healthcare landscape began to shift, similar to innovations seen in primary care over the past 15-20 years, with a focus on incentivizing providers to manage patient care effectively and reduce costs.

The eligibility of ESKD patients for Medicare Advantage plans led to heightened interest from health plans seeking solutions to manage complex patient needs and reduce overall care costs.

As a nephrologist and leader at Somatis, the speaker expressed optimism about the rapid growth and transformation in kidney care, emphasizing the company’s commitment to driving improvements in patient care.

Somatis prepared for its last private round of financing, indicating a strategic move to bolster resources for continued innovation and expansion in kidney care solutions.

Recognizing the significant disparities in kidney care, especially among BIPOC communities, Somatis prioritized understanding and addressing social determinants of health to improve outcomes for marginalized populations.

The stark statistics regarding the first-year mortality and five-year survival rates for ESKD patients highlighted the urgency for effective interventions and support systems in kidney care.

The speaker concluded with a strong belief in the potential for continued advancements in kidney care, emphasizing the importance of collaboration and innovation to enhance patient outcomes and reduce inequities in health care access.

The speaker begins by acknowledging the significant disparities in kidney health, particularly among vulnerable populations, highlighting the urgency to address these inequalities in outcomes for patients with end-stage kidney disease (ESKD).

They emphasize the importance of new therapeutic classes, such as SGLT2 inhibitors, which can delay disease progression and improve mortality rates, but note that access to these medications is crucial for their effectiveness.

The discussion turns to practical barriers that patients face, such as transportation issues that prevent them from accessing necessary medications and treatments, leading to costly hospitalizations.

The speaker describes how their organization, Somatis, operates under a value-based care model that allows them to address these barriers by providing resources, such as transportation, to ensure patients receive the care they need.

They foresee a shift in the standard of care over the next five years towards increased screening and early identification of chronic kidney disease (CKD), partnering with organizations to raise awareness and educate patients about managing their health proactively.

The speaker underscores the importance of patient understanding regarding kidney disease, particularly the need for early management even when symptoms are not present, which is crucial for effective preventative care.

They highlight the excitement surrounding novel treatments and therapeutics that have emerged in kidney care, stressing the importance of improving access and adoption of these innovations to delay disease progression.

The conversation includes a vision for increased innovation in home dialysis and kidney transplantation processes, aiming to remove barriers and improve patient experiences for those with ESKD.

The speaker shares their personal transition from clinical practice to working at a startup, advocating for clinicians to remain engaged in patient care to maintain perspective on the needs and challenges faced by patients.

They conclude by emphasizing the culture at Somatis, where every team member is dedicated to improving patient care, reinforcing the idea that meaningful healthcare innovation must be rooted in addressing unmet patient needs.

The conversation begins with a strong belief in the importance of perspective, highlighting that understanding various viewpoints is crucial in addressing complex issues in healthcare.

Dr. Mikhail expresses a commitment to improving healthcare systems and incentives, indicating a belief that systemic change can lead to better patient care and outcomes.

The discussion underscores the belief that comprehensive care is essential, suggesting that a holistic approach to health can yield significant benefits for patients, particularly those with chronic conditions.

The interaction showcases a value placed on education and knowledge dissemination, as both participants express a desire to learn from each other, reinforcing the idea that sharing insights can foster growth and understanding.

Dr. Mikhail’s insights reflect a belief in the necessity of understanding both the minute details of organ function (micro level) and the broader healthcare system (macro level), suggesting that both perspectives are critical for effective care.

The respectful and engaging nature of the conversation illustrates a belief in the power of dialogue and collaboration among professionals to enhance knowledge and improve practices.

Both participants acknowledge personal learning through their exchange, emphasizing the belief that conversations can be transformative and lead to personal and professional development.

The closing remarks convey a belief in the importance of gratitude and appreciation in professional interactions, suggesting that recognizing contributions fosters a positive and collaborative environment.

The overall tone of the podcast reflects a shared belief in lifelong learning, indicating that both participants are dedicated to continually expanding their understanding of kidney care and healthcare systems.

The conversation culminates in a shared passion for improving patient care, highlighting a core belief that drives both individuals in their professional journeys.

In this episode of the Pulse podcast, co-host Kate Stanton engages in a thought-provoking conversation with Dr. Bassem Mikhail, the Senior Vice President of the Clinical Enterprise at Somatis, a pioneering organization dedicated to transforming kidney care. Founded in 2016, Somatis has made significant strides in partnering with healthcare professionals and community teams to enhance the quality of life for patients with kidney disease, serving over 150,000 individuals across 36 states. Listeners will gain insights into the essential functions of kidneys, the complexities of chronic kidney disease (CKD) and end-stage kidney disease (ESKD), and the staggering costs associated with these conditions—averaging ten times higher per patient than those without kidney disease.

Dr. Mikhail shares his journey into nephrology, highlighting the multifaceted nature of kidney care and the importance of a holistic approach to treatment. He discusses how Somatis is reshaping traditional care models by prioritizing integrated, preventative, and patient-centered care, while also addressing the critical role of federal initiatives aimed at improving kidney care. The episode promises to enlighten listeners about the innovations in kidney care that inspire hope for better patient outcomes, making it an essential listen for anyone interested in healthcare transformation and the future of patient care.

Dr. Bassem Mikhail had a strong influence from his father, who is also a physician, which shaped his desire to pursue a career in medicine.

He has a fascination with the complexity of renal physiology and how kidneys maintain homeostasis in the body.

Dr. Mikhail enjoys the holistic approach required in nephrology, treating patients while considering their overall health and other organ systems.

He appreciates the wide spectrum of disease acuity in nephrology, from intensive care to outpatient settings, allowing him to maintain long-term relationships with patients.

He pursued an MBA during medical school to gain management training, motivated by the need for change in healthcare delivery towards lower costs.

Dr. Mikhail has a keen interest in health policy, which he explored during his undergraduate studies before deciding it wasn’t the right fit for him at that time.

He was drawn to Somatis because of its mission to revolutionize kidney care and focus on patient-centered, integrated care.

He values the opportunity to continue practicing nephrology while also working on strategies to improve care for kidney disease patients at Somatis.

Dr. Mikhail finds optimism in clinical innovations that promise better outcomes for patients living with kidney disease.

He has a passion for creating broad impacts on patient care, aiming to improve the quality of life for thousands of patients across the country.

The guest serves as the Senior Vice President of the Clinical Enterprise at Somatis, where they lead efforts to innovate kidney care delivery.

They emphasize the importance of multidisciplinary care teams that meet patients in their homes to provide proactive care.

The guest is passionate about realigning incentives in the healthcare system to prioritize preventative care over reactive, volume-based medicine.

They express a deep understanding of kidney physiology, highlighting the kidneys’ critical role in maintaining homeostasis rather than just producing urine.

The guest notes that kidneys receive more than 25% of the heart’s output every minute, underscoring their importance despite their small size.

They mention that many patients with chronic kidney disease (CKD) do not experience significant symptoms until the disease has progressed, making early diagnosis crucial.

The guest is aware that approximately 37 million U.S. adults have some form of kidney disease, with 40% of those in advanced stages being unaware of their condition.

They discuss the differences between living and deceased kidney transplantation, advocating for living transplants as the best form of kidney replacement therapy.

The guest highlights the benefits of kidney transplants over dialysis, including improved quality of life and dietary freedom for patients post-transplant.

They express a commitment to working closely with clinical teams and physician partners to improve patient outcomes in kidney care.

The guest emphasizes the complexity of managing chronic conditions in patients with kidney disease due to the kidneys’ regulatory functions in the body.

They highlight the significant difference in healthcare spending between patients with End-Stage Kidney Disease (ESKD) and those without kidney disease, with ESKD patients costing about ten times more.

The guest points out that patients with Chronic Kidney Disease (CKD) experience much higher hospitalization rates compared to those without kidney disease.

They discuss the unique eligibility of ESKD patients for Medicare, making it one of the few conditions that grants access to this insurance.

The guest mentions the historical focus on fee-for-service dialysis rather than incentivizing preventative care and delaying disease progression.

They advocate for a transition towards value-based care models that prioritize patient outcomes over service volume.

The guest emphasizes the importance of addressing social determinants of health and psychosocial needs in the care of kidney disease patients.

They describe Somatis’s approach as holistic, tailoring care to individual patient needs while also considering broader health issues.

The guest notes that the model of care at Somatis includes a strong focus on home care for dialysis patients.

They express a commitment to improving clinical quality outcomes and reducing total costs of care through their innovative care model.

The guest emphasizes the importance of understanding a patient’s home environment, as it significantly impacts their care and access to healthcare services.

They advocate for a multidisciplinary approach in patient care, involving various healthcare professionals such as nurse care managers, social workers, and dieticians.

The guest believes in the value of delivering care at home to address potential barriers that may not be visible in a clinical setting.

They have a strong focus on early engagement with patients, especially those at risk for rapid disease progression, to delay the onset of more severe health issues.

The guest is passionate about managing chronic comorbid conditions alongside kidney disease, highlighting the interconnection between diabetes, hypertension, and kidney health.

They recognize the challenge patients face in navigating multiple appointments and prescriptions from different specialists, which can be overwhelming.

The guest’s model aims to provide a cohesive experience for patients, ensuring they receive comprehensive care without the confusion of juggling various healthcare providers.

They express a strong belief in the importance of aligning incentives among patients, providers, and payers to enhance patient outcomes.

The guest values collaboration with external healthcare providers, including nephrologists, endocrinologists, and cardiologists, to create an integrated care model.

They are committed to improving healthcare delivery by ensuring that all parties involved in a patient’s care work towards the same goal of maintaining the patient’s health and well-being.

The guest is involved in exploring ways to better address chronic kidney disease (CKD) and end-stage kidney disease (ESKD) through innovative care models.

They emphasize the importance of delaying disease progression as a key focus in kidney care.

The guest has a strong belief in the potential of value-based care, drawing parallels with advancements made in primary care over the past 15 to 20 years.

They express optimism about the evolving landscape of kidney care and the regulatory support from CMS (Centers for Medicare & Medicaid Services).

The guest is actively involved in planning a significant financing round for their organization, indicating a forward-looking approach to business growth.

They prioritize health equity and are focused on understanding how social determinants of health impact disparities in kidney care outcomes.

The guest highlights the disproportionate impact of CKD on BIPOC populations, particularly noting the higher prevalence among African American and Hispanic American patients.

They acknowledge the alarming statistics regarding mortality rates for ESKD patients, indicating a serious concern for patient outcomes.

The guest is excited about the rapid growth and transformation in kidney care that they have witnessed during their tenure at Somatis.

They are open to connecting with interested parties for potential collaboration or investment opportunities related to their work in kidney care.

The guest emphasizes the importance of addressing social determinants of health, particularly transportation, as a critical barrier for patients with chronic kidney disease (CKD).

They advocate for increased awareness and education about CKD within communities to promote early identification and screening of the disease.

The guest expresses optimism about the innovation happening in healthcare, particularly in value-based care models that focus on patient outcomes.

They highlight the necessity of clinician involvement in startups to ensure that healthcare innovations meet real patient needs.

The guest believes that maintaining a clinical practice while working in a startup is vital for staying grounded and focused on patient care.

They discuss the significant impact of novel treatments and therapeutics on delaying disease progression in kidney care.

The guest is passionate about improving access to kidney transplants and home dialysis for patients with end-stage kidney disease.

They view the integration of technology in healthcare as a means to enhance patient care delivery.

The guest’s organization, Somatis, prioritizes a culture where every team member is focused on improving patient care.

They stress the importance of patient understanding and awareness about managing kidney disease, even when symptoms are not present.

Dr. Mikhail values the importance of perspective in healthcare discussions.

He emphasizes the need to improve systems and incentives within the healthcare framework.

He expresses a passion for educating others about chronic kidney disease (CKD) and end-stage kidney disease (ESKD).

Dr. Mikhail appreciates engaging conversations that deepen understanding of complex topics.

He believes in addressing challenges on both micro and systemic levels in healthcare.

He enjoys sharing knowledge and insights with others in the field.

Dr. Mikhail finds value in collaborative discussions that lead to learning and growth.

He expresses gratitude for opportunities to participate in educational platforms like podcasts.

He is committed to advocating for better kidney care practices and policies.

Dr. Mikhail enjoys connecting with others who are passionate about healthcare improvement.

Dr. Bassem Mikhail’s aspiration to become a physician was heavily influenced by his father, who was also a doctor, instilling a passion for patient care and a fascination with the human body.

He pursued medical school where he developed a keen interest in renal physiology, drawn by the complexity and elegance of kidney function.

During his clinical years, Dr. Mikhail appreciated the holistic approach required in nephrology, recognizing the kidneys’ central role in overall health and the necessity of integrating general medicine principles into his specialty.

Under the guidance of a clinical mentor, he learned that excelling in nephrology also required a strong foundation in internal medicine, further solidifying his commitment to the field.

He valued the ability to manage a wide spectrum of patient acuity, from intensive care to outpatient settings, fostering long-term relationships with his patients.

After completing his residency and fellowship at Massachusetts General Hospital (MGH), he sought to gain management training through an MBA, recognizing the need for innovative healthcare delivery models.

His early interest in health policy led him to explore ways to impact healthcare delivery on a broader scale, although he ultimately decided to focus on direct patient care.

Dr. Mikhail was drawn to Somatis due to its mission to revolutionize kidney care by prioritizing value-based, patient-centered approaches, aligning with the macroeconomic trends he had studied.

At Somatis, he took on a leadership role while continuing to practice nephrology, enabling him to influence strategies that improve care for patients with chronic kidney disease and end-stage kidney disease.

Today, Dr. Mikhail serves as SVP of the Clinical Enterprise at Somatis, which operates in 36 states and serves over 150,000 patients, focusing on integrated kidney care rather than traditional fee-for-service models.

The kidneys, weighing less than a pound combined, are crucial organs responsible for filtering blood, regulating fluid levels, balancing electrolytes, and maintaining overall homeostasis in the body.

Many individuals with CKD do not experience significant symptoms until the disease has progressed to later stages (CKD stages 4 and 5), making early diagnosis and preventative care essential yet challenging.

The CDC estimates that over 37 million U.S. adults have some form of kidney disease, with approximately 40% unaware of their condition, leading to complications as the disease progresses.

Somatis was established to shift kidney care from a reactive model, focused on in-center dialysis, to a proactive approach emphasizing preventative care, disease progression delay, and improved patient quality of life.

Somatis leverages multidisciplinary care teams that meet patients in their homes, utilizing advanced technology to enhance patient engagement and care delivery.

The organization works closely with physician partners to create value-based care models that align the incentives of physicians and patients, promoting better health outcomes.

As Senior Vice President of the Clinical Enterprise at Somatis, the speaker collaborates with clinical, technology, and physician engagement teams to continuously innovate and advance the clinical model of care.

There are two types of kidney transplants – living and deceased. Living kidney transplants are preferable as they can occur before dialysis is needed, whereas deceased transplants involve waiting for an organ from a donor.

Kidney transplants are the best form of kidney replacement therapy, allowing patients to potentially come off dialysis and return to a lifestyle closer to what they enjoyed prior to their kidney disease.

Despite the benefits, the number of patients receiving transplants is limited by factors such as the availability of donor organs and the need for patients to be placed on waiting lists for deceased transplants.

The conversation begins by highlighting significant barriers to kidney transplantation, particularly the mismatch between the demand for kidneys and the available supply of organs.

It is revealed that approximately 1% of Medicare patients have End-Stage Kidney Disease (ESKD), yet this group accounts for 7% of Medicare spending, illustrating the financial strain posed by kidney disease on the healthcare system.

The average annual cost for a Medicare patient with ESKD is around $90,000, which is significantly higher than the average cost of about $9,000 for patients without kidney disease, emphasizing the financial challenges associated with kidney-related conditions.

The discussion also touches upon Chronic Kidney Disease (CKD), where the costs for patients average around $27,000, indicating that costs are disproportionately higher for patients with kidney issues compared to those without.

Patients with CKD and ESKD experience much higher rates of hospitalization and emergency department visits, with CKD patients being hospitalized three to four times more often than those without kidney disease.

The complexity of managing kidney disease, particularly in relation to other chronic conditions such as hypertension and congestive heart failure, is highlighted as a factor contributing to increased healthcare costs and resource utilization.

The high costs associated with providing dialysis treatment, which typically requires patients to visit treatment centers multiple times a week, are noted as a significant contributor to overall healthcare expenditures for ESKD patients.

The unique aspect of ESKD patients being eligible for Medicare, similar to ALS patients, creates specific dynamics in the healthcare system that affect patients, providers, and stakeholders.

Recent changes by the Centers for Medicare & Medicaid Services (CMS) towards incentivizing delaying disease progression in CKD and ESKD patients reflect a shift from a volume-based to a value-based care model.

Somatis is introduced as a healthcare provider focusing on reducing disease progression and costs through a value-based care model, emphasizing home care and a holistic approach that addresses both kidney-specific and comorbidity-related health needs.

The journey began with the recognition of significant barriers in patient care, particularly related to understanding patients’ home environments and their impact on health outcomes.

To address these challenges, the team developed a robust technology platform that integrates data from various sources to predict high-risk patients and identify potential health crises.

A commitment to home-based care led to the hiring of diverse field-based care teams, including nurses, social workers, and dieticians, to provide comprehensive support to patients in their homes.

The realization that many issues affecting patient health stem from their home environment prompted the teams to assess patients’ living conditions, such as medication management and safety hazards.

A strategic emphasis was placed on engaging patients with early-stage chronic kidney disease (CKD) to delay disease progression through proactive management and education.

The organization began working closely with primary care physicians to ensure early referrals to nephrologists for patients at risk of rapid kidney disease progression.

Recognizing the prevalence of comorbidities like diabetes and hypertension in CKD patients, the team integrated management of these conditions into their care model to improve overall health outcomes.

The organization developed partnerships with external healthcare providers, including nephrologists, endocrinologists, and cardiologists, to create a cohesive care experience for patients navigating multiple specialists.

By adopting risk-based contracts, the organization aligned incentives between patients, providers, and payers, ensuring that all parties worked towards the common goal of improving patient health outcomes.

The culmination of these efforts resulted in a supportive ecosystem that empowers patients, streamlines care delivery, and enhances communication among healthcare providers, ultimately leading to better health outcomes.

Somatis begins its journey in the kidney care space, aiming to address the complexities of managing chronic kidney disease (CKD) and end-stage kidney disease (ESKD) patients.

The Advancing American Kidney Health Executive Order is introduced by CMS, setting ambitious goals to slow the progression of kidney disease, increase home dialysis and transplant rates, and enhance kidney availability for transplants.

CMS develops new payment models, including the Kidney Care Choices (KCC) model, which aligns with the goals of the Advancing American Kidney Health Initiative, incentivizing providers to take on risk and improve patient care.

Increased recognition of the need for value-based care in nephrology, drawing parallels with advancements seen in primary care over the past 15-20 years, leading to a shift in nephrologists’ approach to patient management.

Growth in demand from Medicare Advantage plans for solutions to manage ESKD patients, as they seek to reduce costs and improve care outcomes amidst increasing patient complexity.

Somatis plans for its last round of private financing, indicating rapid growth and the need for strategic investments to further enhance kidney care services.

Somatis prioritizes addressing health disparities in kidney care, recognizing that CKD disproportionately affects BIPOC populations, particularly African American and Hispanic communities.

The organization emphasizes understanding how social determinants impact health outcomes, aiming to mitigate disparities in kidney disease management.

Somatis expresses optimism about ongoing changes in kidney care, anticipating continued growth and transformation in the coming years, driven by regulatory support and a commitment to improving patient outcomes.

The team at Somatis is dedicated to driving advancements in kidney care, with a focus on enhancing support for caregivers and addressing inequities in health outcomes for patients with kidney disease.

The conversation begins with an acknowledgment of the significant disparities in kidney health, particularly for vulnerable populations, highlighting the urgency for solutions to improve outcomes.

The emergence of SGLT2 inhibitors as a new therapeutic class is noted, emphasizing their potential to delay disease progression and improve mortality rates for patients with end-stage kidney disease (ESKD).

A critical barrier to the benefits of these new medications is identified—patients often lack access to necessary medications due to issues like affordability and transportation.

An example illustrates how simple transportation problems can lead to severe health consequences, such as missed medication pickups or dialysis treatments, resulting in costly hospitalizations.

The discussion shifts to the advantages of value-based care models, which allow organizations like Samanas to address transportation gaps, ultimately promoting better health outcomes and reducing costs.

The conversation outlines three main areas expected to evolve in kidney care over the next five years: increased screening and early identification of chronic kidney disease (CKD), adoption of novel treatments, and improved home dialysis and transplantation processes.

The need for patient education and awareness about CKD, especially in its asymptomatic stages, is highlighted as a crucial component in delaying disease progression.

A focus on the importance of adopting new therapeutics and treatment classes to improve patient care and outcomes in kidney disease management is emphasized.

The speaker shares insights from their personal journey from clinical practice to working in a healthcare startup, underscoring the value of clinician involvement in developing solutions that address unmet patient needs.

The final takeaway encourages clinicians considering a transition to care delivery startups to continue practicing medicine to remain grounded in patient care, which is central to improving healthcare systems.

The conversation begins with a focus on the importance of perspective in improving healthcare systems, specifically in the context of chronic kidney disease (CKD) and end-stage kidney disease (ESKD).

The dialogue emphasizes the need to address existing systems and incentives that challenge broad care improvement, highlighting a systemic approach to healthcare.

Dr. Mikhail expresses gratitude for the opportunity to share insights, indicating a collaborative and engaging atmosphere throughout the podcast.

The host, Kate, shares her appreciation for the knowledge gained during the discussion, illustrating the educational value of the conversation.

The conversation delves into the complexities of kidney care, addressing both the micro-level (organ-specific) and macro-level (systemic) issues related to kidney health.

Both participants reflect on the enriching nature of their exchange, signaling a mutual respect for each other’s expertise.

The dialogue wraps up with expressions of thanks and acknowledgment of the importance of continued conversations in the field of kidney care.

The positive experience suggests a potential for future dialogues on related topics, fostering ongoing learning and collaboration.

The podcast serves as a platform to raise awareness about kidney health issues, encouraging listeners to engage with the topic further.

The episode ends on a note of optimism, highlighting the significance of perspective in driving improvements in healthcare systems.