Closing Gaps in CKM Care Starts With Naming an Owner for Every Patient

Closing the gaps that let cardio-kidney-metabolic (CKM) syndrome go unrecognized and undertreated will require health systems to name a clear point of ownership for patients who cross specialties, according to a panel of clinicians who met for a roundtable discussion on the delivery of CKM care. They discussed the importance of shifting more screening and follow-up work to nonphysician staff and the need to lean harder on specialty pharmacy to clear administrative hurdles at a Population Health Roundtable discussion held by The American Journal of Managed Care^® on July 14, 2026, in New York City.

The conversation, moderated by Deepak L. Bhatt, MD, MPH, MBA, director of the Mount Sinai Fuster Heart Hospital, brought together experts from the New York City metro area, including NYU Langone Health, NYU Grossman School of Medicine, and Yale School of Medicine.

CKM syndrome, defined by the American Heart Association (AHA) in 2023 and refined in 2026 guidance from the AHA, American College of Cardiology, American Diabetes Association, and American Society of Nephrology, describes the overlapping pathways linking obesity, diabetes, chronic kidney disease, and cardiovascular disease.^1,2 Panelists called the framework clinically useful but noted that more than 90% of US adults meet criteria for at least stage I disease, making it too broad to act on without a system for triaging who needs what and when.

Who Should Own a Patient Who Sees 4 Specialists?

The panel's central tension was ownership. Shaline D. Rao, MD, chief of the Division of Cardiology at NYU Langone Hospital–Long Island, said she has informally absorbed metabolic and weight management care for her patients with advanced heart failure because no other structure existed to catch them.

“It's hard when you have a syndrome with so many key elements to have a key owner, and it's too much for primary care,” she said. “It's not so easy for any one specialist.”

These patients still need care from nephrology, endocrinology, and cardiology, and the right model of care hasn’t exactly emerged just yet, Rao said.

Olugbenga G. Ogedegbe, MD, MPH, director of the Institute for Excellence in Health Equity at NYU Langone Health, argued that ownership questions trace back to reimbursement: once CMS or a payer funds a service, adoption follows. He pointed to ambulatory blood pressure monitoring, which sat largely unused in primary care for roughly 20 years until payment caught up. Panelists floated a risk-adjusted, hierarchical condition category code tied to CKM stage as one way to align incentives with earlier intervention.

How Task-Shifting Can Close the Screening Gap

Several panelists pointed to urine albumin-to-creatinine ratio (uACR) testing, still inconsistently ordered alongside estimated glomerular filtration rate despite recent guidance, such as the 2024 KDIGO guidelines,³ as a fixable, near-term target. One approach discussed at length was training medical assistants to prompt for uACR collection while rooming patients, rather than relying on physicians to remember mid-visit.

Ogedegbe connected the strategy to a term borrowed from global health policy.

"The World Health Organization has a term for this: task-shifting," he said. "There's a whole policy in low-income countries where you have 1 physician to 50,000 people…. Task-shifting in primary care [means moving] duties that physicians don't have to do to nonphysicians. That's how they stayed ahead of the HIV epidemic. Nurses treat HIV, not doctors."

David M. Charytan, MD, MSc, director of the Division of Nephrology at NYU Langone Health, said the concept reframed work his team was already doing.

"In the next 6 months, I'm going to put task-shifting in all of my grant submissions for the foreseeable future," Charytan said. "I feel like it's what we've been doing; I just didn't have a name for it, and it makes so much sense."

Ralph J. Riello III, PharmD, BCPS, a clinical pharmacy specialist in cardiorenal and metabolic disease at Yale School of Medicine, described specialty pharmacy as an underused partner for the same reason: pharmacists can absorb prior authorizations, patient assistance enrollment, and adherence outreach that otherwise fall to stretched clinic staff.

Why Disparities Persist Even Inside High-Resource Systems

Panelists pointed to specific points where CKM screening breaks down along equity lines. Beyond access to care, Ogedegbe pointed to language concordance and structural bias as separate, compounding barriers within a single health system.

"It doesn't matter how well-educated you are. If you're Black in the health care system, outcomes are poorer," he said. "We've seen this over and over, and it's not about poverty or anything like that. It's about care processes."

Amrita Mukhopadhyay, MD, assistant professor of medicine in the Division of Cardiology at NYU Grossman School of Medicine, added that even patients who self-identify early face bottlenecks once referred, citing wait times of up to 6 months for weight-management specialists at her own institution. Starting earlier with treating and managing CKM and involving other disciplines early on is important, she said. However, that requires a shift toward better screening of patients.

"Recognizing these patients is still a gap, and so is ownership," Rao said. "What I'd like to take back [to my organization] is how we can design better landing zones of ownership for these patients and earlier recognition using our [electronic health records], leveraging its capabilities to try to channel these patients. I think that's very actionable."

Faculty closed by naming what they would carry back to their institutions over the next 6, 12, and 18 months, from embedding more pharmacists in ambulatory clinics to piloting quality metrics tracking uACR completion. Bhatt offered the closing thought.

"In the CKM space, more so than many others, it's really important to have multidisciplinary collaboration—physicians, nurses, pharmacists, probably also involving third-party payers," Bhatt said. "I'm just going to take back the value of making sure that as we're trying to implement CKM strategies in our health system, we actually practice all of what we were just discussing here and not just preach it."

References

1. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. Circulation. 2023;148(20):1606-1635. doi:10.1161/CIR.0000000000001184

2. Writing Committee Members; Ndumele CE, Rodriguez F, Dixon DL, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online June 9, 2026. doi:10.1161/CIR.0000000000001453

3. Kidney disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4S):S117-S314. doi:10.1016/j.kint.2023.10.018