Setting the Stage for Collaborative Care to Address CKM Syndrome

Thinking of the interconnected health conditions of cardiovascular-kidney-metabolic (CKM) syndrome as one entity will help providers begin to address it holistically, Manisha Jhamb, MD, MPH, explained at an Institute for Value-Based Medicine^® (IVBM) event, hosted by The American Journal of Managed Care^® in partnership with University of Pittsburgh Medical Center (UPMC). At the event, health plan, health system, and departmental leaders tackled the urgent challenge of advancing population health and innovative care models for obesity and CKM syndrome.

Jhamb, a nephrologist and director of the Center for Population Health Management at UPMC and chair of the event, emphasized that success in treating CKM syndrome will require breaking down organizational barriers. Moving past disease-specific silos can improve outcomes, enhance patient experience, and reduce costs, she said.

CKM syndrome, which links heart disease, kidney disease, diabetes, and obesity, is a fairly new concept. As a result, multiple clinicians across specialties might be seeing “the same metabolic patient, and this is the same patient who sometimes has this care fragmentation across multiple specialties,” Jhamb said.

Driving Health System Alignment

In the rapidly evolving landscape of health care, where financial pressures collide with an aging and increasingly sicker population, organizations must strike a delicate balance between delivering top-tier clinical care and achieving sustainable value, said Chester Ho, MD, chief medical officer for UPMC Health Plan and chief population health officer at UPMC, who gave the keynote of the event. For systems with both integrated delivery and robust financing arms, the imperative to align provider and payer perspectives has never been greater.

The single most disruptive force in health care finance today is the unprecedented escalation of pharmacy costs. This trend, largely driven by the arrival of high-cost, lifesaving medicines, poses a fundamental challenge to the financial viability of health plans and, by extension, the entire health care ecosystem.

“We have never seen these trends in pharmacy, ever,” Ho noted. “We have incredibly important lifesaving medicines—and we’re still at the tip of the iceberg—but every single one of them is a gajillion dollars. How do we manage that? And what’s the right, appropriate path?”

Specifically looking at glucagon-like peptide-1 (GLP-1) receptor agonists, Ho noted that the health plan’s total annual spend on GLP-1 drugs alone nearly matched its entire pharmacy spend from a decade ago. And he doesn’t expect to see a break in GLP-1 spending until 2027.

Compounding this challenge is the dual trend of an aging population alongside a younger generation grappling with greater chronic illness. This shift is straining capacity and increasing utilization across the continuum of care. Ho pointed out that although the historical goal was to push care from expensive inpatient settings to less-costly outpatient ones, the growth of outpatient services now warrants scrutiny. He believes the pendulum has swung too far in that direction, with too many outpatient services.

For integrated delivery and financing systems, the opportunity lies in leveraging the combined strength of the health plan and the provider group. This strategy seeks to align the health system’s need for revenue to fund innovation with the health plan’s need to control medical costs and maintain premium stability.

Ho stressed that within the health plan’s toolbox—which includes care management, utilization management, and pharmacy levers—the most powerful catalysts for change are strong provider performance and engagement.

Ultimately, Ho’s vision is one of forward momentum, regardless of setbacks. “Even if we stumble forward, forward is good,” he stated, emphasizing a culture of continuous learning and adaptation.

Predictive Modeling in Obesity and CKM

The path toward holistic, value-based care in complex metabolic conditions hinges on the ability to move from reactive treatment to proactive, individualized prediction. The use of big data and machine learning can improve clinical decision-making and overcome barriers in managing obesity and CKM syndrome, explained 2 presenters.

Kathleen M. McTigue, MD, MPH, MS, professor of medicine and vice chair for real-world evidence in the Department of Medicine at the University of Pittsburgh (Pitt), introduced predictive modeling as a tool to support shared decision-making in the challenging landscape of weight-related health. Patients with obesity often face multiple health problems, complicated screening recommendations, and significant social stigma. Prediction models can help by identifying patients likely to develop severe obesity, predicting specific health outcomes, or forecasting treatment responses.

“I think everybody can imagine how having access to [that] information might be able to help with your shared decision-making process,” she said. “Then, of course, the predictive models could help you with evaluating care processes and planning for quality improvement initiatives, and hopefully by doing this, improving your adherence to guideline-concordant care.”

McTigue highlighted how Pitt utilized PCORnet’s real-world data for predictive modeling. She and her team were able to look at outcomes of atherosclerotic cardiovascular disease, sleep apnea, heart failure, type 2 diabetes, and obesity-related cancers and create prediction models and risk estimates for obesity-related complications to be used in clinical decision-making. She noted that the important aspects of a model to consider are that it is user friendly and doesn’t disrupt workflow.

Jaideep Behari, MD, PhD, professor of medicine and director of the UPMC Liver Steatosis and Metabolic Wellness Program at Pitt, followed with a use case focused on metabolic dysfunction–associated steatotic liver disease (MASLD), which he calls “the canary in the metabolic coal mine.” MASLD often precedes conditions like type 2 diabetes and chronic liver failure, making early identification critical. However, current expert-recommended screening pathways—starting with the Fibrosis-4 (Fib-4) score—suffer from real-world limitations such as missing data and low clinical adherence, he said.

Of the new patients he has seen in the last 4 years, 65% fall into a low-risk category and go back to their primary care physician (PCP), 20% already have cirrhosis and are beyond help from approved therapies, and only 15% are at a point where they can be treated. Behari’s team created a machine learning (ML) model to better identify patients who need to be prioritized for risk stratification. Ultimately, the model performed better than the Fib-4.

“This is very exciting, but it’s also very humbling, because I use Fib-4 every single day, and to know that an ML model performs better than me can be pretty humbling,” Behari said.

Closing the Gaps in Chronic Care

In 3 separate presentations, experts detailed effective strategies that successfully translate evidence into improved clinical practice and patient outcomes, starting with Jonathan Yadlosky, MD, a family medicine physician in Pittsburgh, Pennsylvania, who presented findings from an educational intervention aimed at improving chronic kidney disease (CKD) screening in primary care.

His study showed that in-person sessions and electronic reminders increased clinician confidence regarding CKD management and new therapeutics, such as sodium-glucose cotransporter 2 (SGLT2) inhibitors. The intervention led to a statistically significant improvement in urine-based screening, and Yadlosky concluded the model was “efficient and elegant” with “concrete improvements in clinical metrics.”

David Rometo, MD, clinical lead of the Endocrinology Obesity Unit and Weight Management Program at Pitt, discussed treating obesity by moving beyond the traditional body mass index–only definition and focusing on the severity of associated medical problems. He emphasized that effective management requires a comprehensive, intensive lifestyle program, such as UPMC’s Disease Remission in Obesity Programs, in combination with anti-obesity medications or surgery. These programs can include shared medical appointments and meal replacements, and are vital for high-risk patients who need significant weight loss.

Eric Dueweke, MD, MBA, clinical instructor of medicine at Pitt, focused on closing the gap between recommended guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) and actual patient adherence. He noted that despite having effective, low-cost therapy, adherence is low. Dueweke argued that the solution lies in improving clinical operations, not just finding new drugs. Initial efforts, like medication optimization clinics targeting hospitalized patients, had mixed success. His current focus is on proactive intervention through the use of data-driven, targeted e-consults to reach patients with HFrEF in the primary care setting.

The Future of CKM Management

There is a need to treat CKM syndrome—encompassing cardiac, renal, liver, and metabolic conditions such as type 2 diabetes and MASLD—as a single, interconnected entity rather than isolated diseases, panelists explained. The conversation, moderated by Margaret Zupa, MD, MS, assistant professor of medicine at Pitt, highlighted the shared physiological basis, the central role of obesity, and the operational challenges in primary care.

Speakers Behari and Ann-Marie Rosland, MD, MS, director of the Caring for Complex Chronic Conditions Research Center at Pitt, emphasized that CKM conditions are characterized by “interorgan cross talk, and advancing organ dysfunction in one setting pushes the other organs also to get sicker.” This suggests that early intervention on common risk factors, particularly diet and lifestyle, can prevent widespread deterioration.

Linda-Marie Lavenburg, DO, MS, of the Department of Medicine at Pitt, and Rometo discussed the pivotal role of obesity in driving disease through insulin resistance and vascular effects. They stressed the importance of empowering patients with lifestyle and behavioral change programs. Rometo noted the need to meet patients where they are.

“They need a medicine to allow them to stick to the healthier diet because they’re still surrounded by toxic foods and they crave them,” he said. “They might need a medicine to let their brain let them make the choices to eat the food that will prevent their liver disease from progressing.”

The panel discussed how cardiorenal-protective drugs GLP-1 receptor agonists and SGLT2 inhibitors are forcing a collaborative shift, pushing management toward PCPs. Dueweke and Esra Karslioglu-French, MD, MBA, ECNU, associate chief for clinical operations and associate vice chair for ambulatory medicine at Pitt, highlighted that improved communication via e-consults and electronic health record nudges, as well as the use of real-world evidence, are critical for establishing uniform, evidence-based treatment regimens.

Rosland offered a primary care wish list, asking for better access to lifestyle programs and logistical help with complex steps like prior authorization. She argued for predictive models that are integrated and actionable within the clinical workflow. Karslioglu-French supported this, noting, “All of these interactions only work if the PCP thinks they are beneficial.”

The group ultimately advocated for systems to use advanced tools like artificial intelligence and ML to proactively identify patients in earlier disease stages and connect them directly to structured, evidence-based lifestyle and pharmaceutical programs, often bypassing initial provider conversations to reduce stigma and workflow burden.

Payer-Provider Alignment: Incentives, Metrics, and the Cost of Innovation

The final segment of the event focused on the critical intersection of health plan strategy, provider incentives, and the steep cost of novel therapeutics for CKM conditions. The discussion explored how an integrated delivery and financing system (IDFS) can leverage its unique position to lead population health management.

When asked about payment models that reward comprehensive CKM care, Eric Frankel, MD, vice president of the primary care service line at UPMC, emphasized that not all incentives need to be financial. He noted that success in shifting away from fee-for-service toward value-based reimbursement lies in aligning goals.

“I think all physicians, and especially primary care physicians, want to do what’s best for their patients, and that’s their biggest incentive,” Frankel said.

Ho discussed the importance of using comprehensive IDFS data to define metrics and target the right patients for intervention. He advised focusing on conditions that present the greatest financial cost, utilization, and opportunity for improved outcomes.

Ho emphasized the need to “hunt for the hiding patient”—those with the highest risk who are difficult to engage—rather than dedicating resources to low-risk patients who are already adherent. As an IDFS, UPMC can leverage the system’s complete data set to maximize programs that add value and avoid gaps in data and gaps in care.

C. Bernie Good, MD, MPH, director of the Center for Value-Based Pharmacy Initiatives at Pitt and senior medical director of the UPMC Health Plan Insurance Division, addressed the financial challenge of expensive CKM therapeutics, such as GLP-1 receptor agonists, especially given patient churn in commercial and Medicare plans. He drew parallels to the costly initial rollout of hepatitis C antivirals, which later became affordable.

Although drugs like GLP-1s lead to remarkable weight loss, their current cost often overwhelms medical savings, making a short-term return on investment elusive. As an IDFS, UPMC doesn’t just “focus on the pharmacy silo” but can look at the total cost of care.

He noted that the idea of President Donald J. Trump’s Most Favored Nation order would help bring some of the costs of drugs down. Since the IVBM event, Novo Nordisk and Eli Lilly announced that they had reached an agreement with the White House to lower the costs of semaglutide (Wegovy and Ozempic) and tirzepatide (Zepbound).² Plus, Medicare Part D and Medicaid would cover Wegovy and Ozempic through a pilot program.³

“If everyone [with obesity] gets [GLP-1s]…it’ll break the bank,” Good said. “But if the federal government is able to negotiate better [prices]…that will help.”

Author Information: Ms Joszt is an employee of MJH Life Sciences^®, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. Bonavitacola J. Trump executive order could reduce pharmaceutical costs by 59%. AJMC^®. May 12, 2025. Accessed November 12, 2025. https://www.ajmc.com/view/trump-executive-order-could-reduce-pharmaceutical-costs-by-59-

2. McNulty R. Trump announces deals with Lilly, Novo to cut weight loss drug prices. AJMC. November 6, 2025. Accessed November 12, 2025. https://www.ajmc.com/view/trump-announces-deals-with-eli-lilly-novo-nordisk-for-lower-weight-loss-drug-prices

3. Novo Nordisk announces agreement with the U.S. administration to bring GLP-1s to more Americans at a lower cost. News release. Novo Nordisk. November 6, 2025. Accessed November 12, 2025. https://www.novonordisk.com/content/nncorp/global/en/news-and-media/news-and-ir-materials/news-details.html?id=916450