Dr. Bassem Mikhael, Somatus, on realigning incentives to better serve patients with kidney disease

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Dr. Bassem Mikhael, SVP of the Clinical Enterprise, Somatus

In this episode, I sat down with Dr. Bassem Mikhael, SVP, of the Clinical Enterprise at Somatus. Started in 2016 by Dr. Ikenna Okezie, Somatus partners with clinicians, health plans, health systems, and multi-disciplinary community-based care teams to improve health, quality of life, and cost of care for patients with kidney disease. Somatus employs over 1,450 team members and serves more than 150,000 patients across 36 states. Dr. Mikhael 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 10x 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 (ESKD) and how Somatus’ model realigns incentives to focus on integrated, preventative, and patient-centered 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.
• Clinical innovations that make Dr. Mikhael optimistic about the future for patients living with kidney disease.

Beginning — 5:20: Dr. Mikhael’s early interest in medicine

• Childhood career aspirations: To kick off my conversation with Dr. Mikhael, I asked him our usual icebreaker on The Pulse: when you were a kid, what did you want to be when you grew up? He responded that he knew from a young age that he wanted to be a physician. Two main things led to this interest: his fascination with how the body works and his father’s career as a physician.
• Specializing in nephrology: Dr. Mikhael is a nephrologist; so I asked him why he picked this specific specialty. He shared a number of reasons, including:

1. In medical school, he was drawn to the field’s intellectual complexity because of the intricate way in which our kidneys function to maintain homeostasis in our bodies.
2. Later, during his clinical years, he found that he loved the practice of nephrology because of the kidneys’ central role in and impact on overall health.
3. The holistic view required to care for and treat a patient with kidney disease, which incorporates the principles of general medicine and the specialty practice of nephrology.
4. The spectrum of disease acuity that nephrologists manage from very sick patients in the ICU with kidney failure to stable patients in an outpatient clinic or dialysis clinic settings.
5. The longitudinal relationships he could develop with his patients since nephrologists often treat patients for many years.

• Scale of impact: Dr. Mikhael always knew he wanted to have an impact on as many patients as possible. This led him to pursue an MBA while he was in medical school because he recognized that forces outside of medicine would necessitate change in healthcare delivery and payment, and pursuing an MBA provided him with the skills and knowledge needed to drive and support change in care delivery organizations.

5:20–8:55: Somatus Overview

• Joining Somatus: While at Mass General Hospital, Dr. Mikhael got connected with Dr. Ikenna Okezie, the Co-Founder and CEO of Somatus. He loved Dr. Okezie’s vision for changing the delivery of kidney care to focus on delaying disease progression and recentering care around the patient. Somatus was founded in 2016 to revolutionize kidney care and become the world’s best provider of value-based, integrated kidney care. The company partners with nephrologists, PCPs, health plans, and health systems across the US to provide care for patients with or at risk of developing kidney disease. The company operates in 36 states today and cares for over 150,000 patients. To be successful in value-based models that seek to bend the curve of disease and morbidity and improve patient outcomes, Somatus leverages multidisciplinary care teams, builds rich technology solutions, and partners closely with providers to serve as an extension of their practice. Dr. Mikhael’s desire to improve overall outcomes for this patient population and to help many thousands of patients across the country improve their quality of life led him to join Somatus. In addition to working with health plan partners, Somatus works with physicians and physician practices across the country to develop value-based partnerships that invest time upfront in preventative care. In this model of realigned incentives, when the patient does well, so do the providers.

As SVP of the Clinical Enterprise at Somatus, he collaborates closely with the clinical, technology, and physician engagement teams to build, deliver, and execute on the delivery of the company’s clinical model for patients.

8:55–14:26: The complexity of kidney disease diagnosis and management

• What do our kidneys do? When I asked Dr. Mikhael to provide an overview of what care typically looks like for a patient with CKD or ESKD, he first provided an overview of what the kidneys do when they function normally:

Most people are born with two kidneys that together weigh less than a pound. Despite their small size, they play a critical role in maintaining our normal physiology because kidneys produce homeostasis: a state of balance across all internal, bodily systems that is needed for the body to function properly. Kidneys are made up of about a million nephrons, the basic functional unit of the kidney, which work together to allow the kidney to perform the jobs to keep us healthy. Our kidneys also clean and filter our blood of things like acids, potassium, and toxins. Our kidneys regulate the fluid levels in our body to make sure we don’t become too dehydrated or have too much fluid. Furthermore, they regulate our blood pressure and balance the electrolytes in our body, which enable normal functioning of many other organs like our brain and our heart.

• Problems with diseased kidneys: In contrast to the above state of homeostasis, when the kidneys are diseased, they’re unable to complete these basic, essential functions, leading patients to sometimes develop symptoms. If fluids accumulate, patients’ legs can swell and they can develop difficulty breathing due to fluid in the lungs. When the kidneys are not able to clean and filter the blood, electrolyte levels can increase, causing abnormal heart rhythms. Buildup of toxins in the blood can lead patients to experience confusion or cognitive impairment.
• CKD stages: Chronic kidney disease has five stages, one to five, and the later stages of CKD, four and five, represent more severe disease states. The end stage of the spectrum is termed end-stage kidney disease, EKSD. This happens when patients’ kidneys can no longer clean the blood, so they need to receive a form of kidney replacement therapy: a kidney transplant or dialysis.

“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 are essential, but it’s harder to do in [CKD] because patients don’t experience symptoms earlier on…and that leads to a lot of downstream problems for patients as they go through the disease stages.”

• CKD prevalence: Dr. Mikhael highlighted that a challenge of managing CKD is that most patients don’t show significant symptoms until the disease has progressed to its later stages, making early diagnosis and preventative care essential but hard. This partially explains the high prevalence of kidney disease: the CDC estimates that across the country, 37M US adults have some form of kidney disease, but 40% of this population, even when they’re in the advanced disease stages, are not aware of their kidney disease.
• Treatment options: Dialysis and transplants are the two ways to treat ESKD, with dialysis being more common despite transplants being more clinically and cost-effective. Transplants are the best form of kidney replacement therapy as transplants allow patients to come off dialysis and live a life that’s much closer to how they previously lived. However, many barriers to kidney transplants exist including an insufficient supply of transplantable kidneys and a complex transplant process. On the bright side though, Dr. Mikhael shared that he’s seeing a lot of work being done to improve all aspects of the transplant process.

14:26–28:06: System-level innovations

• Cost of CKD and ESKD: Based on the high level of interaction with our healthcare system that patients with kidney disease require, it’s unsurprising that ESKD patients cost about 10 times more than the average Medicare patient without kidney disease. Kidney disease patients have higher rates of mortality, morbidity, hospitalization, and ER visits than patients without kidney disease, which explain these high costs. Because the kidneys regulate so many essential bodily functions, kidney disease complicates the management of other chronic conditions, putting patients at risk for many health challenges. On top of this, our healthcare system largely operates in a fragmented environment, leading to even greater utilization and costs.
• Care model improvements: Throughout our conversation, Dr. Mikhael spoke about incentives, and Somatus’ alignment with optimizing the patients’ outcome. Home care, individually tailored care plans, integration of the patient’s comorbidities like diabetes, high blood pressure, or cardiovascular disease, and addressing the social determinants of health are all essential components of this improved alignment. Somatus executes on each of these by coordinating a team of nurse care managers, patient health advocates, social workers, dietitians, nurse practitioners, and pharmacists to meet with patients in their home, identify care needs, and serve as an extension of the physician practice. Dr. Mikhael and I dug further into home care, and he noted that one of the best things about this approach is that it allows providers to better understand barriers that might exist in accessing care. For example, a loose rug can pose a fall risk and a peek into the refrigerator can provide insight into the patient’s understanding of their nutrition plan.
• Delaying disease progression: For patients in the early stages of CKD, Somatus and PCPs will work closely with the patient to educate them on the importance of getting plugged into the appropriate nephrology care and care for other chronic conditions. Afterall, about half of CKD patients also have diabetes and/or cardiovascular disease or congestive heart failure, and about 90% have high blood pressure. Managing these comorbidities all together, as well as ensuring patients have access to and are taking the proper medications, can have a big impact on delaying progression.

“[Seeing patients in clinic], it’d be very hard for me to know what was going on in their home environment…and so [the Somatus team] will really…serve as physicians’ eyes and ears in the home to identify issues that will be very hard… [to identify] in clinic, like a loose rug…that’s a fall risk…or looking in the fridge to see the patients’ 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.”

• Care coordination: Kidney issues are rarely the only comorbidity these patients live with. Nephrologists play a central role in the care of patients with kidney disease, and Somatus supports the care of these patients by also collaborating with the other physicians and patients’ care teams, including PCPs, endocrinologists, cardiologists, and other specialists. Aside from the fact that better coordination can lower healthcare costs, this coordination gives patients a more cohesive experience. For example, they receive support in juggling multiple appointments with different specialists who all prescribe different medications.

28:06 — End: Government interventions & investments

• Investment in kidney care: CMS and the federal government have made kidney care a priority, recognizing delaying disease progression as the best way to improve outcomes and lower costs. Dr. Mikhael highlighted the importance of the Advancing American Kidney Health Executive Order, which put forth strategies to delay progression and increase home dialysis and kidney transplants. CMMI’s Kidney Care Choices (KCC) model, which essentially allows for a direct contracting model with CMS, as Dr. Mikhael put it, among CMMI’s other models, also represent big steps forward for nephrology’s entry into the world of value-based care.
• Managing risk: I was curious to hear about how federal policy decisions like CMMI models influence business operations planning and risk for Somatus. Dr. Mikhael explained that Somatus was formed in 2016, prior to when the Advancing American Kidney Initiative and KCC model were announced, but that these programs have posed tailwinds as Somatus has grown. In addition, the 21st Century Cures Act, which makes ESKD patients eligible for Medicare Advantage, is another exciting opportunity for growth in value-based kidney care, which is well-positioned to manage care for high-complexity kidney disease patients.
• Increasing access to therapeutics: Due to my interest in strategies for supporting the advancement of health equity, and investing in the social determinants of health, I asked Dr. Mikhael about how his work intersects with each of these areas. He noted that kidney care has been marked by significant disparities in outcomes as the disease disproportionately impacts BIPOC patient populations. According to the CDC, African Americans make up 13% of the US population but over a third of dialysis patients, and CKD is also more prevalent among African American and Hispanic populations. Dr. Mikhael explained how new therapeutic classes like SGLT2 inhibitors, which can help delay disease progression and have a benefit in improving mortality, can help reduce these disparities. That said, beyond making these innovations available, we need to make them accessible because we won’t see improvements if it’s hard for patients to access these medications.
• Closing SDoH gaps: Dr. Mikhael also explained the central role that transportation plays in serving CKD and ESKD patients. For example, CKD patients take many chronic medications like diuretics — water pills to help manage fluid levels — but they need to be able to get to the pharmacy to retrieve these medications. Similarly, when a dialysis patient misses even one treatment, they are at significantly higher risk of being hospitalized. Access to transportation to and from appointments, which occur several times a week, is needed to avoid this. He reminded me that in the traditional environment, there haven’t been incentives to make sure patients can get to the pharmacy or all their appointments. Complicating matters, physicians haven’t had the resources to easily solve these challenges for patients despite transportation being a main barrier to adhering to care plans. However, in the value-based care model, which is at risk for total cost of care, it is possible to invest the resources and incentives to address transportation gaps in order to help patients be healthy at home and avoid very costly hospitalizations.
• Improved standard of care over next five years: I asked Dr. Mikhael for his prediction on the three main ways the standard of care will evolve for CKD and ESKD in the next five years. He shared:

1. Increased screening and early identification of CKD: He noted that Somatus partners with organizations like the National Kidney Foundation and others to increase patient and community awareness and education about CKD, important levers in delaying disease progression.
2. Greater access to novel treatments and therapeutics: There’s been a lot of welcome progress in this area in the last five to ten years, and he’s excited about improving adoption of medications that delay disease progression, something he’s already working on with Somatus’ physician partners.
3. Better access to home dialysis and transplants: As we discussed at other points in this conversation, these two innovations are critical for improving quality of life and outcomes for patients who reach the ESKD stage in kidney disease.

• Advice to other clinicians: I wrapped up our conversation asking Dr. Mikhael for advice to other clinicians on transitioning to care delivery startups. He expressed the importance of having clinicians guide the work of companies innovating in any area of healthcare — biotech, health IT, tech, care delivery — to ensure that the organization is ultimately solving an unmet need for patients. He also encourages clinicians to continue practicing medicine and seeing patients, a very important way to always remain connected to the patient experience. Even though many organizations will impact patient care at a larger scale, it ultimately happens one patient at a time, an essential perspective to keep in mind even when working at a system level.

Earlier in our conversation, Dr. Mikhael also shared that Somatus is kicking off the fundraising process for what’s likely to be the company’s final private funding round. He encourages people interested in learning more to reach out to him!

Thank you Dr. Mikhael for joining us on this episode of The Pulse Podcast! Subscribe for our new releases on Twitter, Spotify or Apple podcasts.