5 Ways Value-Based Kidney Care Can Improve HEDIS Performance

Updated annually by the National Committee for Quality Assurance (NCQA), Healthcare Effectiveness Data and Information Set (HEDIS) measures are used in rating systems including the NCQA Health Insurance Plan Ratings and the Centers for Medicare & Medicaid Services (CMS) Star Ratings to help consumers evaluate the quality of health plans. Closing gaps in care to improve HEDIS scores and, in turn, boost CMS Star Ratings, directly contributes to improved financial performance for health plans in the form of bonuses, opportunities for expansion, and increased reimbursement.

Why should health plans focus on quality improvement among members with CKD?

For health plans, focusing on chronic kidney disease (CKD) care is essential not only to improve patient outcomes, but also to reduce care costs. In 2020, employer-sponsored health plans spent $37,843 per patient per year (PPPY) to manage CKD,¹ compared to Medicare’s spend of $22,660 PPPY.² The gap reflects an opportunity for private plans to significantly bring down the costs of care for their members with CKD.

Fortunately, data shows early detection and cost-effective CKD interventions such as lifestyle modifications, medications, and management of comorbid conditions can effectively slow disease progression and delay the need for transplantation or dialysis, which can cost upward of $100,000 PPPY.³ Additionally, enhanced kidney care coordination strategies can also prevent unnecessary and costly hospitalizations and readmissions. This creates a compelling incentive for health plans to identify opportunities for quality improvement among their members with CKD.

How can health plans close gaps in care and improve HEDIS scores for members with CKD?

Here are five clear areas where value-based care can help plans proactively close care gaps to boost HEDIS scores, improve member outcomes, and manage costs.

1. Increase kidney health evaluation rates for people with diabetes

In 2020, NCQA introduced the Kidney Health Evaluation for Patients with Diabetes measure to improve early kidney disease detection and treatment in people with diabetes, a known risk factor for kidney disease. The measure tracks the percent of adults with diabetes who receive an annual kidney health evaluation, including both an estimated glomerular filtration rate (eGFR), which estimates the volume of blood filtered by the kidneys, and a urine albumin-creatinine ratio (uACR), which measures the amount of albumin protein in urine to determine if the kidneys are filtering properly.

Despite being considered one of the most reliable screening tests for CKD, uACR testing is not routinely performed for patients at risk of developing kidney disease.⁴ According to the United States Renal Data System (USRDS) 2024 Annual Data Report, CKD diagnoses are likely underestimated due to underuse of uACR testing. Alarmingly, in 2023 less than half of Medicare fee-for-service and Medicaid beneficiaries with diabetes received urine screening.⁵ 

Many patients who test below the normal range for eGFR continue to rely on non-nephrologists, including primary care providers (PCPs), for medical care,⁶ which may contribute to the underuse of uACR testing. Value-based care models that focus on whole-patient health and managing comorbidities can help increase uACR testing by increasing access to nephrologists, who routinely perform both eGFR and uACR testing during patient assessments. As part of a value-based approach to kidney care, Interwell Health partners with PCPs to increase coordination with nephrologists, promote early detection and proactive interventions, and address gaps in care.

2. Control high blood pressure for patients with hypertension

For measurement year 2025, NCQA added a HEDIS measure that assesses the percent of adults with hypertension whose blood pressure is adequately controlled.⁷ Hypertension is one of the leading causes of CKD and poorly controlled high blood pressure can also have a negative impact on kidney function, making hypertension a common comorbidity for patients with CKD. In fact, three out of four adults with CKD also have hypertension.⁸

For patients with CKD and hypertension, having a nephrologist on their care team can be an effective strategy to help control high blood pressure in kidney disease. A value-based care approach to kidney care encourages interdisciplinary care coordination across specialties to treat the whole patient, rather than treating coexisting diseases in silos.

Interwell supports development of personalized care management plans and offers interventions such as disease education, prevention-focused health coaching, and referral coordination to help provider partners better manage their patients with cardiovascular disease and CKD. Working with one health plan, for instance, Interwell helped 56 percent of members with CKD and hypertension control their blood pressure.

3. Reduce hospitalizations and readmissions for CKD, one of the leading causes of readmissions

HEDIS includes several measures designed to reduce hospitalizations for potentially preventable complications, emergency department visits for patients with chronic diseases, and unplanned acute readmissions for all causes. While these measures are not specific to CKD, there is a strong opportunity to improve performance among patients with CKD and ESKD given the current high rates of hospitalizations and readmissions.

According to the USRDS 2024 Annual Data Report, the all-cause hospitalization rate is more than twice as high for adults with CKD than those without the disease (452 vs. 194 hospitalizations per 1,000 person years). For adults with stage 4-5 CKD, the hospitalization rate is even higher (774 hospitalizations per 1,000 person years).⁹ Patients with CKD who are hospitalized are at higher risk of complications including readmission, longer stays, worsening kidney function, and higher mortality rates.¹⁰

When it comes to readmissions, CKD is among the top five principal diagnoses with the highest rate of 30-day all-cause adult readmissions.¹¹ More than one in five adult hospitalizations for CKD result in subsequent readmissions within 30 days of discharge—a 33 percent higher readmission rate than in adults without CKD.¹² 

Value-based kidney care management can help reduce initial hospitalization and readmission rates by focusing on early detection, improved access to care, patient education, comorbidity and medication management, and addressing social determinants of health (SDoH). Interwell has a proven track record of reducing hospitalizations and readmissions using predictive analytics and a holistic care model to drive impactful interventions and keep patients out of the hospital.

Impact of Interwell program across all eligible payer lives (from 2022 to 2023):

• Reduced CKD per member per year (PMPY) inpatient admissions by 8 percent
• Reduced ESKD PMPY inpatient admissions by 4 percent

Impact with one Medicare Advantage partner (among 7,500+ ESKD members nationwide):

• Reduced PMPY admits by 18.7 percent
• Reduced readmissions by 17.4 percent

Related reading: The Power of Data: Avoiding Hospitalizations for People with Late-Stage Chronic Kidney Disease

4. Promote depression screening

There are five HEDIS measures for depression care, including Depression Screening and Follow-up for Adolescents and Adults (DSF) and Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS). Depression screening is particularly important among patients with chronic diseases who are at higher risk of experiencing behavioral health issues. Up to 30 percent of people with kidney disease experience depression, a rate that is three times higher than in the general population.¹³

Data show regular depression screening for CKD patients can help identify those in need of support. In 2022, almost 30,000 Interwell patients completed a PHQ-9 screening test, a standardized test to identify signs of depression. Of the 1,561 patients identified with signs of moderate to severe depressive symptoms, more than 71 percent improved to mild or no depressive symptoms during a subsequent screening.

Interwell supports depression screening among CKD patients by providing resources such as workflows to evaluate patients and dedicated tools to alert providers when screening and intervention are needed. Interwell also collaborates closely with payer and provider partners to help patients manage their depression and kidney disease with wraparound support from an interdisciplinary care team including social workers, nurses, advanced practice providers, and care coordination specialists.

5. Identify social determinants of health to better support high-risk patients

In 2023, NCQA implemented a new Social Need Screening and Intervention (SNS) measure to help address healthcare inequities. The measure looks at indicators for screening and intervention across needs related to three major SDoH: food, housing, and transportation.

Social and environmental factors can increase the risk of developing kidney disease and create barriers to care that can contribute to poor outcomes for patients with CKD. Communities of color are disproportionately impacted by SDoH risk factors and CKD prevalence is higher among Black adults (19 percent) than in any other group.¹⁴ The prevalence of ESKD is nearly four times higher among Black adults compared to White adults.¹⁵

During the 2025 public comment period, NCQA proposed adding new codes to the SNS measure to improve health plans’ ability to report performance data.¹⁶ As the landscape for social needs screening continues to evolve, Interwell partners with health plans to build and refine their strategies for measuring and addressing SDoH. This can include using advanced machine learning to identify vulnerable individuals and target interventions where they are most needed.

In addition, Interwell social workers speak with patients about access to nutritious food, their housing conditions, and transportation barriers. For patients in need, Interwell also assists with coordinating transportation to clinical appointments. This comprehensive care model helps ensure patients receive the right support at the right time to address SDoH and improve outcomes.

Achieving better HEDIS scores through value-based kidney care

Adopting a value-based care model isn’t just about improving HEDIS scores and quality ratings; health plans have an opportunity to deliver meaningful improvements in member experience and outcomes, strengthen their financial performance, and build the foundation for sustainable long-term success.

Interwell’s value-based kidney care solution is purpose-built to close gaps in care and improve chronic kidney disease cost management for patients with CKD stage 3 through ESKD. With a unique two-pronged approach of total patient care and provider enablement, Interwell has a proven track record of driving sustainable change to improve health outcomes and financial performance for health plans.

Interested in how value-based kidney care can help improve quality performance and outcomes for your organization? Learn how Interwell partners with payers on our website or contact us today.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

References

¹ Health Payer Intelligence: Understanding Chronic Kidney Disease Coverage, VBC opportunities. https://healthpayerintelligence.com/features/understanding-chronic-kidney-disease-coverage-vbc-opportunities

² Health Payer Intelligence: Understanding Chronic Kidney Disease Coverage, VBC opportunities. https://healthpayerintelligence.com/features/understanding-chronic-kidney-disease-coverage-vbc-opportunities

³ USRDS 2024 Annual Data Report: Healthcare Expenditures for Persons with ESRD. https://usrds-adr.niddk.nih.gov/2024/end-stage-renal-disease/9-healthcare-expenditures-for-persons-with-esrd

⁴ BMJ Open Quality: All Patients with Diabetes Should Have Annual UACR Tests. Why is That So Hard? https://bmjopenquality.bmj.com/content/5/1/u209185.w3747

⁵ USRDS 2024 Annual Data Report: Identification and Care of Patients with CKD. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/2-identification-and-care-of-patients-with-ckd

⁶ National Kidney Foundation. Advanced CKD Care and Decision Making: Which Health Care Professionals Rely on for CKD Treatment and Advice? https://www.kidneymedicinejournal.org/article/S2590-0595(20)30111-4/fulltext

⁷ NCQA: HEDIS MY 2025: What’s New, What’s Changed, What’s Retired. https://www.ncqa.org/blog/hedis-my-2025-whats-new-whats-changed-whats-retired/

⁸ USRDS 2024 Annual Data Report: CKD in the General Population. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/1-ckd-in-the-general-population

⁹ USRDS 2024 Annual Data Report: Morbidity and Mortality in Patients with CKD. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/3-morbidity-and-mortality-in-patients-with-ckd

¹⁰ American Journal of Managed Care: Even Patients With Mild CKD Have Higher Hospitalization Rates, Study Says. https://www.ajmc.com/view/even-patients-with-mild-ckd-have-higher-hospitalization-rates-study-says

¹¹ Agency for Healthcare Research and Quality: Clinical Conditions With Frequent, Costly Hospital Readmissions by Payer, 2020. https://hcup-us.ahrq.gov/reports/statbriefs/sb307-readmissions-2020.jsp

¹² USRDS 2024 Annual Data Report: Morbidity and Mortality in Patients with CKD. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/3-morbidity-and-mortality-in-patients-with-ckd

¹³ Kidney International Reports: Depression in Chronic Kidney Disease and End-Stage Renal Disease: Similarities and Differences in Diagnosis, Epidemiology, and Management. https://www.sciencedirect.com/science/article/pii/S2468024916300845

¹⁴ USRDS 2024 Annual Data Report: CKD in the General Population. https://usrds-adr.niddk.nih.gov/2024/chronic-kidney-disease/1-ckd-in-the-general-population

¹⁵ USRDS 2024 Annual Data Report: Incidence, Prevalence, Patient Characteristics, and Treatment Modalities. https://usrds-adr.niddk.nih.gov/2024/end-stage-renal-disease/1-incidence-prevalence-patient-characteristics-and-treatment-modalities

¹⁶ NCQA Quality Measures Newsletter: HEDIS Public Comment Period Is Now Open. https://www.linkedin.com/pulse/hedis-public-comment-period-now-open-ncqa-g3haf/