Part 3: Following the Spend

Key Takeaways

• Nephrology leads specialty care with 30‑35% patients in risk‑based contracts.
• Specialty spending grew 35% faster than overall market between 2020‑2023.
• Cardio‑kidney total cost of care totals about $608 billion annually.
• $1.6 billion invested in kidney‑care platforms demonstrates scalable models.
• $10 billion funding into cardiometabolic platforms fuels IPO exits and growth.

Pulse Analysis

The fastest growth in U.S. healthcare costs now comes from a handful of high‑intensity specialties. Orthopedics, oncology, cardiology, women’s health, behavioral health and nephrology together account for roughly 38 % of Medicare and commercial spending, and their expenditures rose 35 % faster than the rest of the market between 2020 and 2023. Within that group, kidney care has become the first specialty where value‑based contracts are gaining traction: recent Signals research puts the share of nephrology patients covered by total‑cost‑of‑care arrangements at 30‑35 %, outpacing most peers.

The convergence of cardiovascular and renal disease creates a massive, $608 billion annual total‑cost‑of‑care pool. Yet the payment architecture remains fragmented: a nephrologist may be reimbursed on a risk‑bearing model while the cardiologist treating the same patient still operates under fee‑for‑service. This misalignment incentivizes duplicated testing and prevents coordinated prevention of complications. Companies that can bridge the cardio‑kidney divide—by aligning incentives, sharing data, and delivering joint care pathways—stand to capture a sizable share of one of the largest spend categories in American medicine.

Investors have already poured roughly $1.6 billion into kidney‑focused platforms such as Monogram, Strive and Somatus, and a broader $10 billion has flowed into cardiometabolic digital‑health ventures that are now surfacing IPOs. The emerging thesis is clear: capital follows the spend, not the underlying science. The next wave of funding will target the enabling layer—diagnostics, AI‑driven monitoring, interoperable data infrastructure, and workflow tools—that makes accountable specialty care scalable. As more specialties transition to risk‑bearing contracts, firms that solve execution challenges will shape the future of value‑based healthcare.