How Monogram Health Is Transforming Polychronic Care

_{The author is chair of the board of Monogram Health, and founding partner of Frist Cressey Ventures, where Monogram was started and incubated.}

Nowhere has innovation been more prevalent in recent years than in healthcare – but this astounding progress has not been evenly distributed throughout all sectors of medicine, or among all Americans.

Some types of care – such as cancer care – have seen a night and day difference in clinical outcomes where once terminal diagnoses have become manageable chronic conditions or, in some cases, even entirely curable. Another is my own specialty of heart disease where risk of death from a heart attack in 2015 was half of what it was in 1960.

Other areas of clinical care, however, have been much slower to evolve, failing to modernize to the full benefit of patients and families. For proof, look no further than the care of patients with renal (or kidney) disease, where a patient on dialysis today looks almost identical to a patient on dialysis in the year 2000.

Such was the case until Monogram Health came onto the scene in 2018.

Founded and incubated by Frist Cressey Ventures (FCV) in Nashville, Tennessee, Monogram Health is on the forefront of transforming the long stagnant kidney care industry, which has historically been dominated by highly consolidated dialysis center companies. These in-facility care-providing giants have contributed much by standardizing hemodialysis and improving patient safety, but they have fallen short on maximizing overall value and quality of life for patients. With over half a million Medicare patients on regular dialysis due to end stage renal disease (ESRD), and more than one in seven adults in the U.S. — nearly 37 million people — living with chronic kidney disease (CKD), the opportunity to improve quality of life, to better outcomes, and to lower costs with a new model of care is immense.

Five years ago, the founding Monogram team, led by clinically focused Frist Cressey Ventures and CEO Mike Uchrin, saw the need for long overdue innovation in kidney care engagement and rose to the challenge. Collectively we set out to completely reset the treatment standard for CKD, ESRD, and other polychronic conditions by prioritizing comprehensive, patient-centered care delivered at home, optimally driven by a multispecialty team in the rapidly emerging value-based environment.

Fueled by a fortuitous convergence of recent smart national policy, technological innovation in data management and medical devices, skyrocketing patient demand for care closer to home, a sea change in both patient and provider comfort levels with home-based care complemented with telemedicine, and advances in understanding risk management, Monogram Health – in a highly differentiated way – is leading the charge in modernizing kidney care. Though other outstanding renal-based health service companies are contributing to the much-needed transformation of kidney disease care, the Monogram approach is unique. And the following is how:

Implementing Evidence-Based, Patient-Centric Care in the Home Setting

From the outset, Monogram was founded with the patient and his or her family at the center. Patient centricity is fundamental to the Founders and to the leadership team; it pervades the culture today. This initial vision was well articulated by Monogram’s first Chief Medical Officer and nationally recognized nephrologist, Dr. Raymond Hakim: to raise the quality of care and satisfaction for all patients with CKD and ESRD. And to do so by developing and diligently applying an evidence-driven protocol that leads to better patient outcomes and more cost-effective treatment, all within this costly and growing sector of health care.

Delivering care in the home, where a patient is more comfortable, feels safer, and is likely to be most compliant with appropriate treatment is essential to this vision. Through this approach, Monogram dismantles a longstanding barrier to care by enabling consistent access to patients and their families, which allows us to develop individualized care plans around patient goals, based in trusted relationships.

Three scientifically grounded and evidence-based pathways were developed (and are continually refined as new, proven knowledge unfolds):

· Polychronic disease management: to delay the progression of kidney disease by disciplined, attentive treatment of comorbidities (for example, hypertension and diabetes), with an emphasis on compliance to medication therapy and maximizing social determinants of health;

· Patient and caregiver education: to empower patients with educational tools to make informed decisions about slowing their own disease progression and treatment options, and to make informed decisions if their disease progresses; and

· Management of end stage renal disease: to heighten attention to quality and end-of-life goals, while leveraging the “home-first” approach. Fundamentally, advanced renal disease should not be synonymous with dialysis.

The Patient Journey

Who can enroll in Monogram? Patients access Monogram through their health plan. Monogram has partnered with leading insurance providers including HumanaHUM
, Cigna, Point32Health and CenteneCNC
, as well as leading risk bearing platforms like agilon, Advent and Banner Health, all of whom seek to improve access to evidence-based care while also improving affordability of care. Monogram operates to reach all insurance products, including Medicaid populations. Its home-based care model sees no barrier related to the zip code of a patient.

Monogram works with its partners using proprietary AI-driven algorithms to identify the patients who would most benefit from this additional, personalized support.

Once a patient is enrolled in Monogram, they undergo a comprehensive clinical, medical, and social assessment, conducted in-person with an experienced nurse practitioner from the patient’s locality. The assessment includes screening for depression, inappropriate medication therapy, underlying comorbidities and access to care, as well as social determinants such as transportation and emotional support.

A carefully tailored care plan that includes personalized education is developed based on the assessment. The patient’s care is actively managed by their care providers, including Monogram’s employed group of specialists, ranging from physicians focused on nephrology, endocrinology, and cardiology to internal medicine, palliative care, and other specialties. These physicians work together to collaboratively manage the polychronic care of the patient. And behind that primary care team is a supporting team of nurse practitioners, social workers, pharmacists, nurses, and dietitians who are equipped with specific skill sets to prevent progression of polychronic disease, including chronic and end stage renal disease. They effectively manage complications, and smooth transitions if there are changes in treatment.

If the patient’s renal function deteriorates beyond certain thresholds because of progression of disease, they are assessed for eligibility for transplant, dialysis, or conservative treatment. Active education with shared decision-making is fundamental. Monogram has found that costly, emergency “dialysis crashes” into the hospital are avoidable if disease progression is identified early and an advance care plan has been made and executed.

If the patient is dialysis-eligible and elects to proceed, the Monogram team typically plans for a non-hospital dialysis start with permanent access, encouraging home alternatives to in-center dialysis. For many, peritoneal dialysis (where the inside lining of one’s abdomen acts as a natural filter with a surgically placed catheter) might be the recommended option. Patients are informed of all treatment options rather than, as in the past, automatically defaulting to in-center hemodialysis (where an external machine is used to filter waste from the blood). Other pathways, if clinically indicated, include kidney transplantation or palliative care, considered in consultation with patient, family, caregivers, and the Monogram care team.

The Monogram Difference

What is unique about Monogram Health’s approach?

First, the Nashville-based company sets itself apart with its home-based care model focused on early disease detection and slowing progression of kidney disease, in conjunction with comprehensive treatment for other chronic conditions. A home-first mission means care comes to the patient’s front door, as opposed to the patient carrying the burden of finding the care, then maintaining it with repeated visits, outside their home. Hemodialysis, considered one of the great advancements in the history of medicine, also has challenges, with in-center treatment typically lasting four hours, three times a week. On top of that is the added back-and-forth commute, making it a significant time commitment.

Monogram, instead, gives patients the education and support to manage their illnesses and develop treatment plans that match their diverse health needs, their local social determinants of health, and personal and family goals, starting in the comfort of their own home. Indeed, 98% of our patient visits in 2022 were in the home setting.

The second defining difference is our multidisciplinary team-based approach to care that’s evidence-based and scaled nationally. Polychronic conditions like CKD and ESRD are time and cost burdensome diseases that affect entire families, not just individual patients. Further, they are highly complex medical conditions that commonly co-exist with many other illnesses. Patients are often referred to as many as seven or more specialists which, in traditional care models, often leads to uncoordinated and fragmented care. Monogram’s coordinated team removes the confusion, with each patient receiving a Monogram “Care Advocate” who bridges all scheduled appointments and needs in a seamless experience that makes life easier, more comfortable, and less stressful for patients and their loved ones, all of which contributes to better outcomes and lower costs.

Third are the results. Monogram’s data show how this approach is improving lives and care affordability.

Monogram to date, with the experience of over 66,000 patients across 34 states, has produced results that are better than national averages (from the 2022 USRDS annual report). Monogram patients experience more effective management of their hypertension and A1C. Through the early identification of disease progression program, Monogram reports twice as many planned dialysis starts with permanent access when compared to national averages. And Monogram reports 18% of patients initiating dialysis at home (versus 13.3% national average).

In an A Second Opinion podcast discussion I had in July 2021 with CEO Mike Uchrin, Mike explained how “in-home dialysis by far and away yields much better outcomes, a much better quality of life for the patient because they’re able to dialyze and be treated daily versus every other day in the center,” reducing toxins and fluids in the system as well as avoidable hospitalizations.

The Monogram approach has resulted in a substantial reduction in the 30-day hospital readmission rate averaging 15% across CKD and ESRD patients compared to the national average nearing 30%. Monogram has also seen a marked decrease in 90-day mortality rate after dialysis initiation, compared to national data.

And fourth is the prioritization and dedication to health equity, embedded in the Monogram approach. The Founders (including the author, the team at FCV, and Uchrin) were clear from the outset that this commitment to the underserved would pervade the culture and the approach of the company. Kidney disease, we know, impacts a disproportionate share of disadvantaged communities and communities of color. Monogram has made bold strides in offering patients and families from vulnerable populations enhanced access to much needed health services, while substantially improving the overall affordability of their care.

Over 20% of Monogram’s members are Medicaid and Dual-eligible beneficiaries (individuals who receive both Medicare and Medicaid benefits), who are traditionally more medically complex, experience higher rates of chronic disease, are lower-income, and may have non-medical barriers to better health such as lack of transportation and access to healthy foods.

How Monogram is Helping to Address Medicare’s Burgeoning Costs

The failure to evolve kidney care over the decades has also meant that costs have ballooned where innovation has stagnated.

Since the 1970s Medicare had covered the majority of ESRD care, and the cost has far exceeded original projections. Americans diagnosed with kidney disease account for more than 20% of all Medicare spending. And, between 2009 and 2019, total Medicare expenditures increased 50% for beneficiaries with ESRD, reaching an eye-popping $51 billion in 2019.

Recent policy changes facilitated by both the Obama and Trump Administrations created a landscape where innovation in kidney care could finally flourish, enabling the formation of Monogram Health and other like-minded companies.

Under President Obama, the bipartisan 21^st Century Cures Act was enacted which allowed ESRD patients to enroll in Medicare Advantage plans beginning in 2021, creating a new opportunity for value-based, at-risk care models to engage in advanced kidney disease care. And later under President Trump, we saw a shift to and increase in the availability of covered at-home services, including the launch of new payment models focused on accelerating use of home dialysis and kidney transplantation. The Trump Administration also boosted access to home dialysis by allowing Medicare reimbursement for needed equipment and supplies.

Already, these policy changes have slowed the growth of Medicare expenditures and saved federal taxpayer dollars. More than this, though, providing at home dialysis services has become a preferred treatment method for patients and providers alike and has been shown to improve independence and dignity for the individual, and maintain a higher quality of life.

Changing the Status Quo in Polychronic Care

Monogram is different. The company prioritizes home-first, patient-centric engagement with a nationally scaled, value-based primary and specialty provider platform. We leverage proprietary, scientifically driven and evidence-based interventions. And, we work as far upstream as possible to prevent disease progression, ease transitions of care, and where appropriate lean on conservative kidney management without dialysis.

Healthcare innovation is all about improving the patient experience and clinical outcomes. We are increasing utilization of home dialysis, broadening access, and reducing the number of readmissions and mortality rate. Further, we are minimizing structural barriers to health and wellbeing and providing high quality, meaningful care to all patients, importantly including those who have historically been the most vulnerable and underserved.

Thanks to Monogram Health, a dialysis patient in 2023 looks a lot different than one when the company was founded in 2018. Kidney care has officially modernized, and the Monogram model has laid the groundwork to further modernize care for all chronic conditions in the years to come.