Chronic kidney disease care is moving beyond risk scores. In this episode of Strategy of Health, Cole Lyons speaks with Joseph Vattamattam and Stephanie Toth-Manikowski, MD, MHS, FASN of Healthmap Solutions about next best action, CKD population health, AI/ML-enabled care workflows, care gap prioritization, and value-based kidney care.The conversation covers how Healthmap Solutions helps identify which interventions matter most for complex kidney patients, how clinicians and analytics teams work together, and how better prioritization can improve outcomes while reducing avoidable hospital and emergency department utilization.Guests: Joseph Vattamattam and Stephanie Toth-Manikowski, MD, MHS, FASNHosted by Cole Lyons for the American Journal of Healthcare Strategy.Timestamps00:00 Introduction: kidney care, CKD, and the challenge after risk identification01:21 Why “next best action” matters in chronic kidney disease care04:57 How clinical teams and AI/ML teams work together06:13 A real-world CKD patient example08:16 Recommendation systems, alert fatigue, and physician trust12:20 Turning care gaps into high-impact clinical action15:52 AI, prediction, and personalization in kidney care20:30 Improving outcomes for CKD stage 3 and stage 4 patients23:10 The financial case for better kidney care coordination25:37 Risk-based contracting and aligned incentives28:27 What health plans and providers should ask vendors30:11 Closing thoughts