This episode of Relentless Health Value features Dr. Kenny Cole from Ochsner Health System. The discussion emphasizes the critical role of trusted relationships and excellent primary care teams in keeping patients out of the emergency room, thus reducing healthcare costs.
Stacey Richter revisits this conversation to highlight the importance of care teams building trust with patients and the concept of primary care as an investment in health and wellness. The episode outlines four key points for delivering great primary care, including accountability for outcomes, belief in clinical goals, standardized care flows, and building patient trust.
Dr. Cole also discusses the real-world challenges and strategies for achieving clinical and financial success in primary care. The episode serves as a guide for plan sponsors, clinicians, and healthcare executives looking to improve primary care delivery and align it with financial viability. The discussion is further enriched with insights on digitizing care pathways and the importance of measuring and sharing best practices to achieve high standards of care.I
Stacey revisits, in a take two, this episode with Dr. Kenny Cole because she's listening to it this time with a new focus. That focus is the theme that keeps coming up over and over and over again on Relentless Health Value these past few months.
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07:35 Is there an optimal care pathway where there might be a lot of treatment variability?
10:52 EP412 with Robert Pearl, MD.
12:32 Why is it important to start with the end in mind?
15:44 How do you scale clinical excellence?
18:18 EP315 with Bob Matthews.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Episode 473, Take Two.
This time, listen for how trustedrelationships and excellent primary
care teams keep patients out of theER and other high cost care settings.
Plan sponsors, taxpayers, hi,this is extremely relevant.
Today I speak with Dr. Kenny Cole.
(00:28):
American Healthcare Entrepreneurs andExecutives, You Want to Know, Talking.
Relentlessly Seeking Value.
I'm revisiting in a take two.
This episode with Dr. KennyCole because I'm listening to
it this time with a new focus.
That focus is the theme thatkeeps coming up over and over and
(00:49):
over again on Relentless HealthValue these past few months.
If primary care teams do not have,among other things, but if care teams or
somebody on the care team doesn't builda trusted relationship with plan members
slash patients, then in a moment thatreally matters, the patient slash member
will suboptimally wind up in the ER.
(01:10):
And if this happens across an entire plan,sponsors member population, all these
pilgrimages to the ER, it comes at greatcost to the patient, the plan and society
really, both clinically and financially.
ER spend these days is about6% of average plan spend.
That's nuts.
6%.
And this is why, as Denise Wisemanwrote the other day on LinkedIn,
(01:33):
and I loved how she put it.
She said, "Primary care isabsolutely an investment in
health and wellness, not a cost.
Trust is the foundation withouttrusted relationships between
patients and care teams.
We're not investing, we're just reacting.
And as you Stacey Richter", that'sme, "and others have pointed
out, we are reacting in the mostexpensive setting possible: The ER".
(01:55):
So thanks for writing that, Denise.
But this whole concept, a trustedrelationship with a primary care team.
It could feel soft and squishy, andit is so easy for someone looking at
a spreadsheet to cross off as wastedspend or wasted time and time is money.
So cross off the things that it willtake to build these relationships.
Either this, or good primary care fallsvictim to the very, very real perverse
(02:20):
incentives to drive commercial ER volumeor volume to high revenue service lines.
Just stating facts.
It's logical.
Listen to the show with Dr. Vivian Hoabout some of the perverse financial
incentives in play here for hospitals.
One with Dr. Scott Conardand the show with Al Lewis.
There's a bunch of adjacent points.
So, yeah, let's consider this conversationwith Dr. Kenny Cole today through the
(02:43):
lens actually of what is required so thatprimary care can live up to its potential
to be an investment in the real world.
And that means recognizingwhat it actually takes to
deliver great primary care.
Trust being a piece of this.
Yeah, I'm gonna echowhat Matt McQuide said.
If you aren't getting your members atrusted advisor, who will be there for
(03:04):
them when it matters and when there'simportant decisions being made about
where to go for something big, someoneelse is gonna steer that member and
they're steering based on their ownfinancial incentives and interests.
Dr. Kenny Cole is from Ochsner HealthSystem, and I loved this conversation.
I loved it the first time and Iloved it the second time because
it has lessons for plan sponsors onwhat to look for, that's for sure.
(03:28):
But it also will speak to anybodyworking in a clinic or managing a clinic
or who wants to learn from a master.
This show is also very intriguing foranybody who's trying to work with or for
a clinical practice or a health systemthat is pulling away from the status quo.
One that is earning thetrust of its patients.
And also one that is figuringout how to reinvent the business
(03:49):
model such that the best practiceclinical pathways and care flows are
aligned with financial viability.
That's really the holy grail there.
We talk about how to achieve thisclinical and financial success, even
if the financial models are all overthe map, which they so often are.
The show today sums up four main pointsby my counting, and they are as follows.
(04:10):
I'm just gonna recap them here, butDr. Kenny Cole gets into them from a
level of deep personal understanding,so please do listen to the show.
The four points are (04:18):
clinical teams have to deliver care in such a way that
those clinical teams are accountablefor the outcomes that are generated.
That's number one.
Number two, clinical teams needto really see with their own two
eyes and believe that a clinicalgoal that has been set is possible.
Number three, care flows are criticalhere, which means getting everyone on the
same page about what best practice carelooks like and operationalizing how that
(04:43):
clinical excellence will be achieved.
Number four, the theme that keepscoming up building trust with
patients and connecting withpatients cannot be underestimated.
And care flows need to not onlystandardize care so that it can be
delivered quicker and easier, butalso facilitate patient relationships.
There are a whole bunch of shows besideseven what I already mentioned that
(05:04):
are relevant and adjacent to this one.
I am going to put a long list of them inthe show notes where you can also find a
transcription of everything I just said.
Dr. Kenny Cole, as Imentioned, works at Ochsner.
He is a primary care internist.
He sees patients one day aweek, and the other days serves
as a system vice president.
In this role, he designs anddevelops new care models.
(05:27):
New topic for just a sec. Whatalways warms my heart is when it
comes to you lot, you listening.
There's so much that is wonderfulabout this Relentless Tribe of ours.
To that end, I want to share withyou that I got a call recently
from Kelly Paul from Idaho.
Kelly said that she wants to sponsoran episode because she wants to
contribute to Relentless Health Value.
(05:49):
She says she listens all the timeand just wants it to give back.
Lemme tell you, it's people likeKelly who keep me motivated here.
I had a chance to meet Kelly and Ilearned a lot, and this is not her
day job, but she has a small business.
So on the side, she makes functionalaccessories for cochlear implants
for kids and adults to helpkeep their devices in place.
And as soon as I heard that, of course Iwanted to mention it, even if it's just
(06:13):
to honor a small business owner solvinga problem that needs to be solved.
I mean, it's hard enough to have akid, it's hard enough to deal with
deafness and also have an expensivedevice that could easily go missing.
Kelly's website isciretentionsolutions.com.
So check it out if you have a need.
Support Kelly, and thanks somuch to Kelly for sponsoring
(06:34):
the show with Dr. Kenny Cole.
Oh, also, hey you lot you tribe.
Did you know that the lasttime that we got a review on
Apple Podcast was last October?
Do you believe that?
It was an amazing review.
Don't get me wrong, it starts "Whythis New York City nurse trusts
Relentless Health Value", from theone and only Michelle Bernabe, who I
think from the bottom of my heart andI could not have appreciated it more.
(06:58):
Read a great post by Michelle Bernabeon how we can get the heart back into
healthcare Link in the show notes.
But yeah, if you have not yet writtena review, please give me a shout out.
There's instructions for howto do this on the website.
It does really matter, and if you takethe time to do it, please know you rock.
And with that, here is myconversation with Dr. Kenny Cole.
This podcast is sponsored by, as I justsaid, Kelly Paul, thank you so much.
(07:21):
And also by Aventria Health Group.
Dr. Kenny Cole, welcome toRelentless Health Value.
Thank you for having me.
Nice to be here.
I'm trying to figure out howto kick off this interview to
make a really strong point.
That point is that in many chronicconditions such as diabetes, which is
one big kahuna of a chronic condition,but there's a treatment plan, a clinical
(07:43):
pathway that is in fact optimal.
Yeah.
Let's just take that example of metformin.
You're not gonna find any disagreementamong clinicians that metformin should
be the foundation of pharmaco therapyfor the treatment of type two diabetes.
But where you are gonna find lots ofclinically unwarranted practice pattern
variation is in how many or whatpercentage of patients who are prescribed
(08:07):
metformin are able to tolerate it ina way that they're taking it without
suffering from the GI side effects.
And so when you're corralling thatclinically unwarranted variability,
you have to begin to look atevery single variable that may
potentially cause that person to notbe able to tolerate the metformin.
(08:27):
You're doing things likelevel setting the expectation.
You're assuring the patient that theoverwhelming majority of people will
tolerate it as long as they take it withfood, and that the type of food they're
taking it with matters tremendously.
That when they get the balance ofprotein to carbohydrates wrong, and
if they have too many carbohydrates.
(08:49):
That's when they're gonnaget the GI side effects.
And so I, for example, I would havea smart phrase embedded within my
electronic medical record that'ssimply called tolerating metformin.
I wrote it myself.
I give examples of the types of foods thatthey could use to balance out and take it.
And then what you do is you, youjust engage in these iterative and
recursive loops of learning, right?
(09:10):
Because anytime you have apatient who's not tolerating it.
You're immediately digging inof, okay, why, what happened?
Let's go through your meals.
Let's understand what you did, whatyou could have done differently.
And then you're educating and you'rejust continuing to do that until you
have achieved as large a proportion aspossible of your patients tolerating
metformin, which uh, over the last severalyears, I've typically been 98, 99%.
(09:35):
98 or 99% of patients onmetformin, which is a gold standard
here, as you said, is amazing.
Many patients can't take metformin dueto these GI side effects, and then they
wind up either with disease progressionor on other drugs that obviously they
weren't the first choice so you windup with large swaths of patients, a
(09:58):
big proportion of a population notgetting the gold standard pathway for
reasons that are maybe overcomeable.
If that's a word
.In these new models of care that I design, one of the things that my
doctors, I will teach them very earlyon is it is not the patient's job to
comply with what we tell them to do.
(10:19):
It is our job to earn their trustand then go on a journey with them
where we help them to accomplishwhat matters most to them.
It's not about them complying oradhering to what we tell them to do.
It's about how effective are we atcommunicating and building that trust
and building that rapport, and thenin essence, leading them on a journey
(10:43):
where we co-produce a desired healthoutcome preferentially one that
matters most to the patient themselves.
So that we're appealing to theirintrinsic source of motivation.
What you're saying is it very alignswith the conversation that I had actually
with Dr. Robert Pearl and what he saidwas, there is a science of medicine.
I mean, not all the time.
There's plenty of circumstanceswhere there actually isn't
(11:05):
a whole lot of evidence.
So let's just take thoseoff the table right now.
If we're talking about a circumstancelike this diabetes patient where there's
a ton of evidence relative to what isthe right treatment plan, that's the
science of medicine, and the only timethat science of medicine should be
deviated from, is based on the patientpreference, and that's the art, what the
patient wishes to co-produce with you.
(11:26):
That's right.
I am and want to be held fullyaccountable for the outcomes that
I am co-producing with patients.
And so if a patient is not takinga medication the way that I would
want them to or so forth, then it isnow my job to uncover the barriers,
the obstacles, the challenges.
(11:48):
It may very well mean having tocorrect some type of misperception.
I've told other physicians thatlike, look, if a patient is not
taking the statin that you prescribethem because their neighbor's uncle
developed bad muscle aches whiletaking it, and they're just now scared.
All it means is they trust their neighbormore than they trust their doctor.
(12:08):
And so part of what the doctorneeds to be able to do is to earn
that trust, and I think that's themost essential part of that doctor
patient relationship is buildingthat rapport and earning that trust.
Once you do that, now you have this clearpath to be able to unleash the science in
a way where the patient trusts the sciencebecause they trust you, the doctor.
(12:32):
I'm trying to contemplateeverything you are saying from a,
let's improve the health of thisentire population standpoint.
So figuring out how to operationalizetraining your clinical team and just
in the real world, execute consistentlyacross the whole patient population.
You know, not have some patientssome of the time, get some of what
(12:53):
might be considered best practicecare, depending on which clinician
they see or what day it is.
And we had a conversation about thisbefore, actually, you and I, and you
said, let's begin with the end in mind.
You do start with the end in mind and,and so that is gonna be the outcomes
that matter most to the patients, right?
I've never met a patient who wants to goblind from their diabetes or who wants
(13:16):
to be debilitated by stroke or who wantsto have heart failure because they spent
years of with uncontrolled hypertension.
What we have failed to dothus far in healthcare is even
really define what health is.
For example, sticking with thetheme of diabetes for a moment.
Somebody who's, if the greatest love oftheir life is fishing, you've gotta be
(13:37):
able to have good sensation to be ableto feel that line when a fish bites.
To appeal to their intrinsic source ofmotivation, I want to be able to help them
fish for as many years as I possibly can.
But essential to that is going tobe the control of their diabetes
instead of some arbitrary, our goalwas to get your A1C less than seven.
Which may not mean thatmuch to the patient.
(13:59):
Our goal is be for you to be able tofish for as many years as possible.
And to do that, we've gotta preventthe numbness that's gonna come
in your fingers and your feet.
And in order to do that, we'regonna have to control your sugar.
And what that control of your sugar lookslike is gonna be an A1C of seven, and
that's gonna be the measure that we'regonna use to make sure we're achieving
that goal that matters most to you.
(14:20):
And so fully interpreting it in thatway, and then backing up from there
to then begin with what the careflowlooks like from the beginning.
Here's my big question.
I have a conundrum for you, Dr. Cole.
Because, you're delivering clinicalexcellence to your patients.
I mean, if you have 90 plus percentof your patients on metformin, and you
(14:43):
told me before that you think 95% bloodpressure control is what the standard
should be, which is gonna blow somepeople's minds right now because across
the rest of the country, if, if bloodpressure is 70, 75% controlled, people
think they're doing amazing work.
So we have the situation where you'vegot an amazing clinician who knows how
to have the conversation about phishingand who sets up the conversation in
(15:06):
that way, then you get patients who areintrinsically motivated because they
understand what the risk is here andwe're giving them a sense of control.
Like, here's how you can monitorto make sure that you don't
wind up having these risks.
It makes a ton of sense.
On the other hand, you're gonnatalk to a lot of clinicians like
Dr. John Rodis is a medical directorover at QC Health and we're doing
(15:30):
a lot of stuff with kidney disease.
We've had plenty of conversationswith clinicians who don't tell their
patient that they have progressingkidney disease because in air quotes,
they don't wanna scare the patient.
So like I'm trying to figure out howdo you scale clinical excellence?
The first thing is you show itcan be done like you show what
(15:51):
is the new standard of care.
What should be acceptable because yes,I do believe that the future standard
of care will be that anything less than90 to 95% rates of diabetes control
is gonna be considered substandard.
Anything less than probably 95%rate of hypertension control is
gonna be considered substandard.
Again, in terms of your chronickidney disease question, it goes
(16:14):
back to that whole question of trust.
I often tell patients in my firstvisit, or first or second visit with
them, I'll ask them what their goalsare, but I'm gonna let them know that
I only have one goal and my one andonly goal is to earn their trust.
Then once you earn that trust, you can'tbetray that trust by not telling them
about their chronic kidney disease.
Instead, you have to be open andhonest about what you're seeing and
(16:38):
you might even want to calculate their,the kidney failure risk equation,
both a two year and five year risk.
You can let 'em know whatthe percentage looks like.
Then you can let 'em know that you'reright there with them and that the
goal is that we can reverse that.
That we can actually by better controllingblood pressure and by better controlling
diabetes, and by making sure that we'readdressing the cardiovascular risk
(16:59):
factors appropriately to reduce the riskof cardiovascular, you know, an adverse
cardiovascular outcome, because of course,that is the leading cause of death, even
in chronic kidney disease, that you'reright there with them and that you're
gonna do it together, and that here'show we're gonna get there together.
And you lay out that scenario andthen what you'll see, for example,
I do have a patient who, when shefirst came to me, her two year
(17:21):
kidney failure risk equation was 5%.
Her five year kidney factorrisk equation was 14%.
I saw her just last week.
Her blood pressure's been perfectlycontrolled for the last two years.
Her A1C has been 6.5 or 6.7 and hernew two year and five year kidney
failure risk equation is 0.2% fortwo years and 0.7% at five years.
(17:43):
That's what's possible.
And so I think in terms of scaling itacross a health system, you have to
illustrate the art of what's possible.
And then you really have to understandthe difference between what are
our sequential care processes andwhat are iterative care processes.
And how do you sort of blend thosetwo together across a population
to achieve clinical excellence?
(18:06):
Okay.
Definitely wanna dig intohow to create care processes.
Let me just take one step back for a sec.
I really wanna make sure I'm totallyclear on a really foundational point here.
Bob Matthews was on the podcast a coupleof years ago, and one of the things
that he was talking about is that theabsence of care standardization, using
(18:27):
best practices of care in any sort ofconsistent organizational way, if you
don't do that, the most you'll achieveis like you'll get to 70% of whatever
you're striving for because you'regonna have great doctors doing amazing
work, and then you're gonna have notgreat doctors or not great clinicians
not doing amazing work, and it's gonnaaverage out, so you're going to get 70%.
(18:50):
It's easy to say, let's get trust withall of our patients, and you're gonna
have great clinicians who are able todo that, but that does not achieving
organizational excellence make.
So when you talk about illustratingthe art of what is possible,
does that mean basically saying,look, this is what's achievable.
(19:10):
And then relying on, like Dr. MartyMakary was on the pod, this is
several years ago now, basicallysaying doctors are very competitive.
So if you basically show them whattheir peers are doing, they'll level up.
Is that what you're talking about?
Well, I think that's exactly it.
I'm glad you mentioned Bob Matthews.
I mean, he was really oneof the ones who's kind of
started me on my own journey.
The first time I heard him, I hadjust become chairman of medicine
(19:32):
for a a large multi-specialty group.
And so I challenged our group to achievegreater than an 80% rate of control.
I actually made the mistake whenI first presented it that Kaiser
in California had a 84% rate ofcontrol across 600,000 people.
To which of course, they quickly toldme, well, of course it's California
. They're skinny, they eat right.
(19:53):
How can you compare, you know,California's, Louisiana here.
I mean, with the salt in ourdiet and our obesity, there's no
way we could ever achieve that.
But yet when we actually measured theresults, what we had was a 60% rate of
hypertension control, which at the timethey thought was probably the best we
were gonna get in a state like Louisiana.
When we looked at where did that 60%come from, it came from the fact that
(20:15):
we already had some physicians who were80% rate of control, and we had other
physicians that were 40% rate of control.
We realized that 80 percent's possible,and then the improvement phase is
building out your clinical pathway.
And as more and more doctors startto adopt the clinical pathway and
use it, it was, I think about fiveyears later where that multi-specialty
(20:35):
clinic won the award among mid-sizegroups as having the top rate of
hypertension control in the country.
Part of it is leadership.
It's showing what's possible.
Part of it is transparency, andyes, I do think all doctors at
heart want to do what's right.
It's just that when you're not measuringand holding yourself accountable for
outcomes and really doing an in-depthanalysis of the data to understand
(20:57):
where the improvement opportunitieslie, you get these kind of false
suppositions that are things like,well, of course we're not gonna be
able to get greater than 80% rate ofcontrol, not with our population, right?
Our patients are sicker thanthe rest of the country.
Which of course that's a standardreply for many doctors, when
confront them about their owndata is their patients are sicker.
(21:18):
And so you have to overcome thosebarriers with physicians the same
way you need to overcome obstacles,barriers and challenges with patients.
You just need to discover what theyare, address 'em, and move forward.
You're beginning this whole thingwith illustrate what's possible
and I'm kind of reminded of thewhole thing with Roger Banister.
Everybody thought the fourminute mile could not be beaten.
(21:38):
So it wasn't, and then all ofa sudden Roger Banister ran
faster than a four minute mile.
The second that he did that andshowed that it was possible,
like the record was broken insix weeks or something like that.
There's so much power, I think,in just showing what's possible.
How you articulated that was that youshowed that even in the state of Louisiana
(22:01):
with all of the issues that you talkedabout, you had some doctors achieving
80% blood pressure control and thenothers that were only achieving 40.
So like all of a sudden you showwhat's possible to them and you create
a higher bar that everybody then.
they realized is in fact possible.
It's worth throwing your back into it.
You, you can do it,somebody else is doing it.
(22:24):
Um, so also a little bit of competitivespirit there, but all of that lies
on a foundation of you have tobe measuring what you're doing.
This was a big part of theconversation with Rik Renard.
If anybody wants to go back and listento that show and the point that Rik made.
If you aren't measuring the resultsof your work, then you cannot improve.
(22:45):
You cannot find best practice carebecause how would you even know that
there was a doc with 80% control andeverybody should check out what he or
she was doing and try to emulate it.
In sum, we've gotta show what's possible.
Like everybody has tosee it and believe it.
And then number two, measure.
And then number three, and probablynot to be underestimated, Dr. Sanat
(23:09):
Dixit said this on LinkedIn, he said,doctors don't caucus as well, right?
So like you have to have kindof a culture where everyone
believes in this whole mission.
For me, the care flows, the carepathways, I mean, all of that.
Is simply part of what needs to be doneto arrive where we're really trying to
end up, which is how do you actuallyreinvent the business model of healthcare
(23:32):
such that you are achieving financialand economic viability by doing what's
best for patients, meaning that you'rekeeping them out of the hospital, you're
keeping them out of the emergency room,you're preventing them from having
bypass surgery or stents, or you'repreventing them from being on dialysis.
And, unfortunately in the traditionalhealthcare system, all of those things
(23:54):
are revenue to the health systems.
Now, I'm not trying to say that there'sanything malicious going on, but the
health systems have traditionally stuckby the logic of no margin, no mission,
meaning that we, we have to achieve acertain amount of revenue in order to pay
for the infrastructure that is capableof improving health and health outcomes.
(24:14):
And so, big health systemswill employ primary care
physicians typically at a loss.
The primary care docs will lose money,and then those docs, their incomes
will be subsidized by the stentsand the bypass surgeries, and all
of the downstream revenue that comesfrom what is in essence, a primary
care design model that is designedthrough the fee for service lens.
(24:39):
Insert from the future, and here we go.
The theme of how undermining good primarycare looks very good on paper sometimes
only in the short term, though, mind you,for some health system leadership teams
. Listen to the show with Dr. Vivian Ho.
As I mentioned in the intro.
And I'm saying this withoutjudgment, I'm saying this as a fact.
This is happening across the country andplan sponsors especially, just really
(25:02):
need to be aware of this because, yeah.
Besides the show with Dr. Vivian Ho, thatI just mentioned, also listened to the one
show with Rob Andrews that I mentioned inabout two seconds, which reiterates really
everything I just said about incentives.
This is something so under appreciatedlike that if I think like a health system,
failing primary care is a great boon tobusiness if all we care about is revenue.
(25:27):
And Rob Andrews talked about thiswith respect to NICU stays for babies
on episode 415, and he said supersuccinctly, Hey, look, there's no
hospital administrator on the planetwho's trying to drive up NICU admissions.
But at the same time, these admissions,are very profitable while doing
really great maternal care, or reallygreat primary care is usually in the
(25:50):
current fee for service, FFS modelthat doesn't reward cognitive work.
Like there's no money herefrom a health system standpoint
to have great primary care.
One of my favorite quotes in all ofthis is a quote from Upton Sinclair who
says, it's impossible for someone tounderstand something if their income
depends on understanding the opposite.
I do believe there are some probablyhealth system payer executives and large
(26:14):
health system executives where that sortof holds true right and sympathizing
with the health system executives,they've got a tough road as they kind
of crank up the value driven model ofprimary care while having to still pay
for all the fixed cost of the traditionalmodel of volume driven primary care.
And now looping back to the very beginningof our conversation where you said it
doesn't matter where you are in the caretransformation journey, having care flows,
(26:42):
determining whether also you said, arethese care flows sequential or iterative?
Like really thinking through all of that.
You could do that in a feefor service environment.
Dr. Scott Conard was on the showtalking about how even in a fee for
service environment, he did in factimprove primary care results, and he
had a number of suggestions for howto do that, but even he ran up against
(27:03):
the barrier that you're talking about.
At a certain point, you windup having perverse incentives
that will undermine you.
In the case of Dr. Scott Conard,which is a really interesting podcast,
if anyone didn't listen to it, Iwould encourage you to go back.
Here he was reducing hospital admissions,and you know what the local hospital did?
They bought him and closed him down.
Spoiler alert.
(27:24):
Then at the same time, I'm thinkingto myself when you were talking
about the metformin example,it's a long patient interaction.
Like how long would it take to go throughall the stuff that you were talking about
and create that trust with this patient?
If I've got seven minutes or 15minutes with the patient, this
would be very difficult to achieve.
And if and as a PCP, I'm still tryingto hit my 8,000 RVUs or whatever the
(27:45):
heck it is per year, I just can't evendo these things because just the whole
model of care is set up against me.
Yeah, it really is.
But even so let's think about it evenin a fee for service lens, and I'll
never forget, uh, back when I wasin practice at that multi-specialty
group, one of my partners who was.
Alpha Omega Honor MedicalSociety, finished near the top
(28:07):
of his medical school class.
There was no doubt this physicianwas a really good doctor.
One of his patients happened to endup on my schedule and they were on,
gosh, 25, 30 different medications.
Their blood pressure was really high.
If you don't have an organized wayof how you're going to approach
that patient, it's gonna take youa long time to sort through and
(28:28):
it'll make for a much longer visit.
But what I, at that point,you know, I had a hypertension
algorithm burned into my head.
So I'm going down thislist of medications.
First thing I'm doing is I'm lookingfor either an ACE inhibitor or
an angiotensin receptor blocker.
You know, and like I, I find that.
And then I go down and I findthat the patient was actually
on two different diuretics.
(28:49):
Probably didn't need to beon two different diuretics.
And so, okay, there's someroom for thinking through this.
So for me it's, I'm lookingfor an, an ACE inhibitor or
an antisense receptor blocker.
Then I'm looking for a calciumchannel blocker, probably amlodipine.
Next I might be lookingfor a thiazide diuretic.
This was before a, a trial that justkept published in December of 2021.
(29:10):
But, and this is how the beauty ofthese algorithms in these care pathways.
As new data becomes available, you justmodify the care pathway and you do that.
And you do that for everyone,it ends up being this wonderful,
simplistic way of approaching care.
But like going back to thatpatient who I saw from my partner.
It made it such a quicker, easier visitbecause I was able to just go through
(29:32):
in a very quick sequential manner,quickly jettison a few medications,
add another one, get them on the righthypertension path, and lo and behold,
we get the blood pressure controlled.
That's the beauty of care flows.
It speeds up clinical processing anddecision making and thinking, and then
ultimately where it's gonna go, isanytime you can turn something into
(29:55):
an algorithm, you can indeed digitizeit and then you can create digital
workflows that sort of take someof that work off of the physician.
Which is gonna be necessary becausethere aren't enough hours in the day
for primary care physicians to doall the things they need to do for a
panel of say, 2,500 or 3,000 patients.
I talked with Dr. Beau Raymondon a show about how Ochsner is
(30:18):
starting to digitize are pathways.
Just to underline with six colors,the point that we know how to
deliver amazing primary care.
We know it.
It's just like Dave Chase alwayssays, healthcare is already fixed.
We know how to transform healthcare.
There are solutions available.
We just have to get thosesolutions adopted broadly.
And this is a perfect example of this.
(30:42):
I was thinking as you were talking, sojust my takeaways from what you just said.
If you have a good care flow, thena lot of the cognitive burden is
lifted off of the clinician in thatmoment so that you can use the time
to create trust or do the importantwork of connecting with the patient.
The other thing with the careflow,it's going to enable the clinician to
(31:05):
work with the rest of the team i.e.to make sure that patient actually
shows up for the follow up visit.
There's a lot of other things thatcan happen that spiral around that
clinical visit, which we didn't reallytalk about today, but are obviously
very important for anyone who'sspent 10 minutes trying to do this.
I think what we keep kind of comingback to both the science and the art
(31:26):
of medicine are really important andhave to be present and accounted for.
And standardizing care flows well andmaking sure that we've illustrated what
is possible and there's a culture in theorganization of trying to achieve it.
All of these are essential ingredientsto make sure that the level of care
is consistent across the organizationand as high as it possibly can be.
(31:49):
Dr. Kenny Cole, is there anything thatyou wanna add to this conversation.
I'll add just very briefly,no detail is too small.
For example, in something that youjust said, a careflow is not just,
you start with an angio receptorblocker and an ACE inhibitor, and
then next you add amlodipine, andthen next you add a thiazide diuretic.
A careflow can also include thesimple matter of, you schedule the
(32:12):
patient to come back to get theirblood pressure checked in a few weeks,
but if that patient doesn't showup, if they don't come back, well
that's a huge gap in your care flow.
Your care flow needs toensure that they come back.
And so the way that I first didthis, the very first time I created
something was in the electronicmedical record we were using.
There was a littlebutton called Remind Me.
And so literally I would go upand just click, remind me blood
(32:35):
pressure check in two weeks, orblood pressure check in four weeks.
If the patient came back in four weeks,we would delete the reminder, but if
the patient didn't come back, you wouldput in a date and their name would
essentially turn red, and if their nameturned red, then that just executes a
workflow for the nurse to call 'em andmake sure that they're coming back.
So care flows are very detail orientedand that you're trying to discover
(33:00):
any variable that could potentiallylead to a failure to achieve the
control that you're trying to achieve.
You can do this for blood pressure,for diabetes, for hyperlipidemia,
for you can do it for any one of 'em.
And when you do it wellfor all of them, right?
Because for me it's not abouthaving 95% rate of hypertension
control or 95% diabetes control.
(33:23):
It's about having 95 to a hundred percenthypertension control and 95 to a hundred
percent diabetes control, and 95 to ahundred percent of my patients who have
known vascular disease having theirLDL less than 70, and that they're not
smoking cigarettes, and if they have knownvascular disease that they're on secondary
prevention with antiplatelet therapy.
(33:44):
It's getting all of those ands,and when you get all of those ands
concomitantly, like the percentagethat I'm gonna wanna measure my doctors
and my redesign care models is abundled metric of how often are they
getting all of those things right?
What is that percentage?
That's the percentage we're gonnatry to optimize because if we do,
that's when we're truly gonna impactthe downstream poor health outcomes
(34:06):
of strokes, heart attacks, endstage kidney disease, et cetera.
Once we get to that ideal percentage,that's when we will have achieved
what is truly the art of the possible.
That is very inspiring.
Dr. Kenny Cole, if people areinterested in learning more about your
work, where would you direct them?
I write in these journal articles.
It's nothing prestigious.
It's a local healthcare journal.
I've written about 11 differentarticles in that local healthcare
(34:29):
journal, and a lot of that has manyof the things that we've spoken about.
We will link to them in the show notes.
Dr. Kenny Cole, thank you so much forbeing on Relentless Health Value today.
Thank you.
It was a pleasure being with you.
Hey, this is Matt McQuaidwith Synergy Healthcare.
I listen to Stacey and RelentlessHealth Value every single week.
There's valuable information everysingle week to take from it, and I
(34:50):
just so appreciate this is around.
Episode 473, Take Two.
This time, listen for how trustedrelationships and excellent primary
care teams keep patients out of theER and other high cost care settings.
Plan sponsors, taxpayers, hi,this is extremely relevant.
Today I speak with Dr. Kenny Cole.
(00:28):
American Healthcare Entrepreneurs andExecutives, You Want to Know, Talking.
Relentlessly Seeking Value.
I'm revisiting in a take two.
This episode with Dr. KennyCole because I'm listening to
it this time with a new focus.
That focus is the theme thatkeeps coming up over and over and
(00:49):
over again on Relentless HealthValue these past few months.
If primary care teams do not have,among other things, but if care teams or
somebody on the care team doesn't builda trusted relationship with plan members
slash patients, then in a moment thatreally matters, the patient slash member
will suboptimally wind up in the ER.
(01:10):
And if this happens across an entire plan,sponsors member population, all these
pilgrimages to the ER, it comes at greatcost to the patient, the plan and society
really, both clinically and financially.
ER spend these days is about6% of average plan spend.
That's nuts.
6%.
And this is why, as Denise Wisemanwrote the other day on LinkedIn,
(01:33):
and I loved how she put it.
She said, "Primary care isabsolutely an investment in
health and wellness, not a cost.
Trust is the foundation withouttrusted relationships between
patients and care teams.
We're not investing, we're just reacting.
And as you Stacey Richter", that'sme, "and others have pointed
out, we are reacting in the mostexpensive setting possible: The ER".
(01:55):
So thanks for writing that, Denise.
But this whole concept, a trustedrelationship with a primary care team.
It could feel soft and squishy, andit is so easy for someone looking at
a spreadsheet to cross off as wastedspend or wasted time and time is money.
So cross off the things that it willtake to build these relationships.
Either this, or good primary care fallsvictim to the very, very real perverse
(02:20):
incentives to drive commercial ER volumeor volume to high revenue service lines.
Just stating facts.
It's logical.
Listen to the show with Dr. Vivian Hoabout some of the perverse financial
incentives in play here for hospitals.
One with Dr. Scott Conardand the show with Al Lewis.
There's a bunch of adjacent points.
So, yeah, let's consider this conversationwith Dr. Kenny Cole today through the
(02:43):
lens actually of what is required so thatprimary care can live up to its potential
to be an investment in the real world.
And that means recognizingwhat it actually takes to
deliver great primary care.
Trust being a piece of this.
Yeah, I'm gonna echowhat Matt McQuide said.
If you aren't getting your members atrusted advisor, who will be there for
(03:04):
them when it matters and when there'simportant decisions being made about
where to go for something big, someoneelse is gonna steer that member and
they're steering based on their ownfinancial incentives and interests.
Dr. Kenny Cole is from Ochsner HealthSystem, and I loved this conversation.
I loved it the first time and Iloved it the second time because
it has lessons for plan sponsors onwhat to look for, that's for sure.
(03:28):
But it also will speak to anybodyworking in a clinic or managing a clinic
or who wants to learn from a master.
This show is also very intriguing foranybody who's trying to work with or for
a clinical practice or a health systemthat is pulling away from the status quo.
One that is earning thetrust of its patients.
And also one that is figuringout how to reinvent the business
(03:49):
model such that the best practiceclinical pathways and care flows are
aligned with financial viability.
That's really the holy grail there.
We talk about how to achieve thisclinical and financial success, even
if the financial models are all overthe map, which they so often are.
The show today sums up four main pointsby my counting, and they are as follows.
(04:10):
I'm just gonna recap them here, butDr. Kenny Cole gets into them from a
level of deep personal understanding,so please do listen to the show.
The four points are (04:18):
clinical teams have to deliver care in such a way that
those clinical teams are accountablefor the outcomes that are generated.
That's number one.
Number two, clinical teams needto really see with their own two
eyes and believe that a clinicalgoal that has been set is possible.
Number three, care flows are criticalhere, which means getting everyone on the
same page about what best practice carelooks like and operationalizing how that
(04:43):
clinical excellence will be achieved.
Number four, the theme that keepscoming up building trust with
patients and connecting withpatients cannot be underestimated.
And care flows need to not onlystandardize care so that it can be
delivered quicker and easier, butalso facilitate patient relationships.
There are a whole bunch of shows besideseven what I already mentioned that
(05:04):
are relevant and adjacent to this one.
I am going to put a long list of them inthe show notes where you can also find a
transcription of everything I just said.
Dr. Kenny Cole, as Imentioned, works at Ochsner.
He is a primary care internist.
He sees patients one day aweek, and the other days serves
as a system vice president.
In this role, he designs anddevelops new care models.
(05:27):
New topic for just a sec. Whatalways warms my heart is when it
comes to you lot, you listening.
There's so much that is wonderfulabout this Relentless Tribe of ours.
To that end, I want to share withyou that I got a call recently
from Kelly Paul from Idaho.
Kelly said that she wants to sponsoran episode because she wants to
contribute to Relentless Health Value.
(05:49):
She says she listens all the timeand just wants it to give back.
Lemme tell you, it's people likeKelly who keep me motivated here.
I had a chance to meet Kelly and Ilearned a lot, and this is not her
day job, but she has a small business.
So on the side, she makes functionalaccessories for cochlear implants
for kids and adults to helpkeep their devices in place.
And as soon as I heard that, of course Iwanted to mention it, even if it's just
(06:13):
to honor a small business owner solvinga problem that needs to be solved.
I mean, it's hard enough to have akid, it's hard enough to deal with
deafness and also have an expensivedevice that could easily go missing.
Kelly's website isciretentionsolutions.com.
So check it out if you have a need.
Support Kelly, and thanks somuch to Kelly for sponsoring
(06:34):
the show with Dr. Kenny Cole.
Oh, also, hey you lot you tribe.
Did you know that the lasttime that we got a review on
Apple Podcast was last October?
Do you believe that?
It was an amazing review.
Don't get me wrong, it starts "Whythis New York City nurse trusts
Relentless Health Value", from theone and only Michelle Bernabe, who I
think from the bottom of my heart andI could not have appreciated it more.
(06:58):
Read a great post by Michelle Bernabeon how we can get the heart back into
healthcare Link in the show notes.
But yeah, if you have not yet writtena review, please give me a shout out.
There's instructions for howto do this on the website.
It does really matter, and if you takethe time to do it, please know you rock.
And with that, here is myconversation with Dr. Kenny Cole.
This podcast is sponsored by, as I justsaid, Kelly Paul, thank you so much.
(07:21):
And also by Aventria Health Group.
Dr. Kenny Cole, welcome toRelentless Health Value.
Thank you for having me.
Nice to be here.
I'm trying to figure out howto kick off this interview to
make a really strong point.
That point is that in many chronicconditions such as diabetes, which is
one big kahuna of a chronic condition,but there's a treatment plan, a clinical
(07:43):
pathway that is in fact optimal.
Yeah.
Let's just take that example of metformin.
You're not gonna find any disagreementamong clinicians that metformin should
be the foundation of pharmaco therapyfor the treatment of type two diabetes.
But where you are gonna find lots ofclinically unwarranted practice pattern
variation is in how many or whatpercentage of patients who are prescribed
(08:07):
metformin are able to tolerate it ina way that they're taking it without
suffering from the GI side effects.
And so when you're corralling thatclinically unwarranted variability,
you have to begin to look atevery single variable that may
potentially cause that person to notbe able to tolerate the metformin.
(08:27):
You're doing things likelevel setting the expectation.
You're assuring the patient that theoverwhelming majority of people will
tolerate it as long as they take it withfood, and that the type of food they're
taking it with matters tremendously.
That when they get the balance ofprotein to carbohydrates wrong, and
if they have too many carbohydrates.
(08:49):
That's when they're gonnaget the GI side effects.
And so I, for example, I would havea smart phrase embedded within my
electronic medical record that'ssimply called tolerating metformin.
I wrote it myself.
I give examples of the types of foods thatthey could use to balance out and take it.
And then what you do is you, youjust engage in these iterative and
recursive loops of learning, right?
(09:10):
Because anytime you have apatient who's not tolerating it.
You're immediately digging inof, okay, why, what happened?
Let's go through your meals.
Let's understand what you did, whatyou could have done differently.
And then you're educating and you'rejust continuing to do that until you
have achieved as large a proportion aspossible of your patients tolerating
metformin, which uh, over the last severalyears, I've typically been 98, 99%.
(09:35):
98 or 99% of patients onmetformin, which is a gold standard
here, as you said, is amazing.
Many patients can't take metformin dueto these GI side effects, and then they
wind up either with disease progressionor on other drugs that obviously they
weren't the first choice so you windup with large swaths of patients, a
(09:58):
big proportion of a population notgetting the gold standard pathway for
reasons that are maybe overcomeable.
If that's a word
.In these new models of care that I design, one of the things that my
doctors, I will teach them very earlyon is it is not the patient's job to
comply with what we tell them to do.
(10:19):
It is our job to earn their trustand then go on a journey with them
where we help them to accomplishwhat matters most to them.
It's not about them complying oradhering to what we tell them to do.
It's about how effective are we atcommunicating and building that trust
and building that rapport, and thenin essence, leading them on a journey
(10:43):
where we co-produce a desired healthoutcome preferentially one that
matters most to the patient themselves.
So that we're appealing to theirintrinsic source of motivation.
What you're saying is it very alignswith the conversation that I had actually
with Dr. Robert Pearl and what he saidwas, there is a science of medicine.
I mean, not all the time.
There's plenty of circumstanceswhere there actually isn't
(11:05):
a whole lot of evidence.
So let's just take thoseoff the table right now.
If we're talking about a circumstancelike this diabetes patient where there's
a ton of evidence relative to what isthe right treatment plan, that's the
science of medicine, and the only timethat science of medicine should be
deviated from, is based on the patientpreference, and that's the art, what the
patient wishes to co-produce with you.
(11:26):
That's right.
I am and want to be held fullyaccountable for the outcomes that
I am co-producing with patients.
And so if a patient is not takinga medication the way that I would
want them to or so forth, then it isnow my job to uncover the barriers,
the obstacles, the challenges.
(11:48):
It may very well mean having tocorrect some type of misperception.
I've told other physicians thatlike, look, if a patient is not
taking the statin that you prescribethem because their neighbor's uncle
developed bad muscle aches whiletaking it, and they're just now scared.
All it means is they trust their neighbormore than they trust their doctor.
(12:08):
And so part of what the doctorneeds to be able to do is to earn
that trust, and I think that's themost essential part of that doctor
patient relationship is buildingthat rapport and earning that trust.
Once you do that, now you have this clearpath to be able to unleash the science in
a way where the patient trusts the sciencebecause they trust you, the doctor.
(12:32):
I'm trying to contemplateeverything you are saying from a,
let's improve the health of thisentire population standpoint.
So figuring out how to operationalizetraining your clinical team and just
in the real world, execute consistentlyacross the whole patient population.
You know, not have some patientssome of the time, get some of what
(12:53):
might be considered best practicecare, depending on which clinician
they see or what day it is.
And we had a conversation about thisbefore, actually, you and I, and you
said, let's begin with the end in mind.
You do start with the end in mind and,and so that is gonna be the outcomes
that matter most to the patients, right?
I've never met a patient who wants to goblind from their diabetes or who wants
(13:16):
to be debilitated by stroke or who wantsto have heart failure because they spent
years of with uncontrolled hypertension.
What we have failed to dothus far in healthcare is even
really define what health is.
For example, sticking with thetheme of diabetes for a moment.
Somebody who's, if the greatest love oftheir life is fishing, you've gotta be
(13:37):
able to have good sensation to be ableto feel that line when a fish bites.
To appeal to their intrinsic source ofmotivation, I want to be able to help them
fish for as many years as I possibly can.
But essential to that is going tobe the control of their diabetes
instead of some arbitrary, our goalwas to get your A1C less than seven.
Which may not mean thatmuch to the patient.
(13:59):
Our goal is be for you to be able tofish for as many years as possible.
And to do that, we've gotta preventthe numbness that's gonna come
in your fingers and your feet.
And in order to do that, we'regonna have to control your sugar.
And what that control of your sugar lookslike is gonna be an A1C of seven, and
that's gonna be the measure that we'regonna use to make sure we're achieving
that goal that matters most to you.
(14:20):
And so fully interpreting it in thatway, and then backing up from there
to then begin with what the careflowlooks like from the beginning.
Here's my big question.
I have a conundrum for you, Dr. Cole.
Because, you're delivering clinicalexcellence to your patients.
I mean, if you have 90 plus percentof your patients on metformin, and you
(14:43):
told me before that you think 95% bloodpressure control is what the standard
should be, which is gonna blow somepeople's minds right now because across
the rest of the country, if, if bloodpressure is 70, 75% controlled, people
think they're doing amazing work.
So we have the situation where you'vegot an amazing clinician who knows how
to have the conversation about phishingand who sets up the conversation in
(15:06):
that way, then you get patients who areintrinsically motivated because they
understand what the risk is here andwe're giving them a sense of control.
Like, here's how you can monitorto make sure that you don't
wind up having these risks.
It makes a ton of sense.
On the other hand, you're gonnatalk to a lot of clinicians like
Dr. John Rodis is a medical directorover at QC Health and we're doing
(15:30):
a lot of stuff with kidney disease.
We've had plenty of conversationswith clinicians who don't tell their
patient that they have progressingkidney disease because in air quotes,
they don't wanna scare the patient.
So like I'm trying to figure out howdo you scale clinical excellence?
The first thing is you show itcan be done like you show what
(15:51):
is the new standard of care.
What should be acceptable because yes,I do believe that the future standard
of care will be that anything less than90 to 95% rates of diabetes control
is gonna be considered substandard.
Anything less than probably 95%rate of hypertension control is
gonna be considered substandard.
Again, in terms of your chronickidney disease question, it goes
(16:14):
back to that whole question of trust.
I often tell patients in my firstvisit, or first or second visit with
them, I'll ask them what their goalsare, but I'm gonna let them know that
I only have one goal and my one andonly goal is to earn their trust.
Then once you earn that trust, you can'tbetray that trust by not telling them
about their chronic kidney disease.
Instead, you have to be open andhonest about what you're seeing and
(16:38):
you might even want to calculate their,the kidney failure risk equation,
both a two year and five year risk.
You can let 'em know whatthe percentage looks like.
Then you can let 'em know that you'reright there with them and that the
goal is that we can reverse that.
That we can actually by better controllingblood pressure and by better controlling
diabetes, and by making sure that we'readdressing the cardiovascular risk
(16:59):
factors appropriately to reduce the riskof cardiovascular, you know, an adverse
cardiovascular outcome, because of course,that is the leading cause of death, even
in chronic kidney disease, that you'reright there with them and that you're
gonna do it together, and that here'show we're gonna get there together.
And you lay out that scenario andthen what you'll see, for example,
I do have a patient who, when shefirst came to me, her two year
(17:21):
kidney failure risk equation was 5%.
Her five year kidney factorrisk equation was 14%.
I saw her just last week.
Her blood pressure's been perfectlycontrolled for the last two years.
Her A1C has been 6.5 or 6.7 and hernew two year and five year kidney
failure risk equation is 0.2% fortwo years and 0.7% at five years.
(17:43):
That's what's possible.
And so I think in terms of scaling itacross a health system, you have to
illustrate the art of what's possible.
And then you really have to understandthe difference between what are
our sequential care processes andwhat are iterative care processes.
And how do you sort of blend thosetwo together across a population
to achieve clinical excellence?
(18:06):
Okay.
Definitely wanna dig intohow to create care processes.
Let me just take one step back for a sec.
I really wanna make sure I'm totallyclear on a really foundational point here.
Bob Matthews was on the podcast a coupleof years ago, and one of the things
that he was talking about is that theabsence of care standardization, using
(18:27):
best practices of care in any sort ofconsistent organizational way, if you
don't do that, the most you'll achieveis like you'll get to 70% of whatever
you're striving for because you'regonna have great doctors doing amazing
work, and then you're gonna have notgreat doctors or not great clinicians
not doing amazing work, and it's gonnaaverage out, so you're going to get 70%.
(18:50):
It's easy to say, let's get trust withall of our patients, and you're gonna
have great clinicians who are able todo that, but that does not achieving
organizational excellence make.
So when you talk about illustratingthe art of what is possible,
does that mean basically saying,look, this is what's achievable.
(19:10):
And then relying on, like Dr. MartyMakary was on the pod, this is
several years ago now, basicallysaying doctors are very competitive.
So if you basically show them whattheir peers are doing, they'll level up.
Is that what you're talking about?
Well, I think that's exactly it.
I'm glad you mentioned Bob Matthews.
I mean, he was really oneof the ones who's kind of
started me on my own journey.
The first time I heard him, I hadjust become chairman of medicine
(19:32):
for a a large multi-specialty group.
And so I challenged our group to achievegreater than an 80% rate of control.
I actually made the mistake whenI first presented it that Kaiser
in California had a 84% rate ofcontrol across 600,000 people.
To which of course, they quickly toldme, well, of course it's California
. They're skinny, they eat right.
(19:53):
How can you compare, you know,California's, Louisiana here.
I mean, with the salt in ourdiet and our obesity, there's no
way we could ever achieve that.
But yet when we actually measured theresults, what we had was a 60% rate of
hypertension control, which at the timethey thought was probably the best we
were gonna get in a state like Louisiana.
When we looked at where did that 60%come from, it came from the fact that
(20:15):
we already had some physicians who were80% rate of control, and we had other
physicians that were 40% rate of control.
We realized that 80 percent's possible,and then the improvement phase is
building out your clinical pathway.
And as more and more doctors startto adopt the clinical pathway and
use it, it was, I think about fiveyears later where that multi-specialty
(20:35):
clinic won the award among mid-sizegroups as having the top rate of
hypertension control in the country.
Part of it is leadership.
It's showing what's possible.
Part of it is transparency, andyes, I do think all doctors at
heart want to do what's right.
It's just that when you're not measuringand holding yourself accountable for
outcomes and really doing an in-depthanalysis of the data to understand
(20:57):
where the improvement opportunitieslie, you get these kind of false
suppositions that are things like,well, of course we're not gonna be
able to get greater than 80% rate ofcontrol, not with our population, right?
Our patients are sicker thanthe rest of the country.
Which of course that's a standardreply for many doctors, when
confront them about their owndata is their patients are sicker.
(21:18):
And so you have to overcome thosebarriers with physicians the same
way you need to overcome obstacles,barriers and challenges with patients.
You just need to discover what theyare, address 'em, and move forward.
You're beginning this whole thingwith illustrate what's possible
and I'm kind of reminded of thewhole thing with Roger Banister.
Everybody thought the fourminute mile could not be beaten.
(21:38):
So it wasn't, and then all ofa sudden Roger Banister ran
faster than a four minute mile.
The second that he did that andshowed that it was possible,
like the record was broken insix weeks or something like that.
There's so much power, I think,in just showing what's possible.
How you articulated that was that youshowed that even in the state of Louisiana
(22:01):
with all of the issues that you talkedabout, you had some doctors achieving
80% blood pressure control and thenothers that were only achieving 40.
So like all of a sudden you showwhat's possible to them and you create
a higher bar that everybody then.
they realized is in fact possible.
It's worth throwing your back into it.
You, you can do it,somebody else is doing it.
(22:24):
Um, so also a little bit of competitivespirit there, but all of that lies
on a foundation of you have tobe measuring what you're doing.
This was a big part of theconversation with Rik Renard.
If anybody wants to go back and listento that show and the point that Rik made.
If you aren't measuring the resultsof your work, then you cannot improve.
(22:45):
You cannot find best practice carebecause how would you even know that
there was a doc with 80% control andeverybody should check out what he or
she was doing and try to emulate it.
In sum, we've gotta show what's possible.
Like everybody has tosee it and believe it.
And then number two, measure.
And then number three, and probablynot to be underestimated, Dr. Sanat
(23:09):
Dixit said this on LinkedIn, he said,doctors don't caucus as well, right?
So like you have to have kindof a culture where everyone
believes in this whole mission.
For me, the care flows, the carepathways, I mean, all of that.
Is simply part of what needs to be doneto arrive where we're really trying to
end up, which is how do you actuallyreinvent the business model of healthcare
(23:32):
such that you are achieving financialand economic viability by doing what's
best for patients, meaning that you'rekeeping them out of the hospital, you're
keeping them out of the emergency room,you're preventing them from having
bypass surgery or stents, or you'repreventing them from being on dialysis.
And, unfortunately in the traditionalhealthcare system, all of those things
(23:54):
are revenue to the health systems.
Now, I'm not trying to say that there'sanything malicious going on, but the
health systems have traditionally stuckby the logic of no margin, no mission,
meaning that we, we have to achieve acertain amount of revenue in order to pay
for the infrastructure that is capableof improving health and health outcomes.
(24:14):
And so, big health systemswill employ primary care
physicians typically at a loss.
The primary care docs will lose money,and then those docs, their incomes
will be subsidized by the stentsand the bypass surgeries, and all
of the downstream revenue that comesfrom what is in essence, a primary
care design model that is designedthrough the fee for service lens.
(24:39):
Insert from the future, and here we go.
The theme of how undermining good primarycare looks very good on paper sometimes
only in the short term, though, mind you,for some health system leadership teams
. Listen to the show with Dr. Vivian Ho.
As I mentioned in the intro.
And I'm saying this withoutjudgment, I'm saying this as a fact.
This is happening across the country andplan sponsors especially, just really
(25:02):
need to be aware of this because, yeah.
Besides the show with Dr. Vivian Ho, thatI just mentioned, also listened to the one
show with Rob Andrews that I mentioned inabout two seconds, which reiterates really
everything I just said about incentives.
This is something so under appreciatedlike that if I think like a health system,
failing primary care is a great boon tobusiness if all we care about is revenue.
(25:27):
And Rob Andrews talked about thiswith respect to NICU stays for babies
on episode 415, and he said supersuccinctly, Hey, look, there's no
hospital administrator on the planetwho's trying to drive up NICU admissions.
But at the same time, these admissions,are very profitable while doing
really great maternal care, or reallygreat primary care is usually in the
(25:50):
current fee for service, FFS modelthat doesn't reward cognitive work.
Like there's no money herefrom a health system standpoint
to have great primary care.
One of my favorite quotes in all ofthis is a quote from Upton Sinclair who
says, it's impossible for someone tounderstand something if their income
depends on understanding the opposite.
I do believe there are some probablyhealth system payer executives and large
(26:14):
health system executives where that sortof holds true right and sympathizing
with the health system executives,they've got a tough road as they kind
of crank up the value driven model ofprimary care while having to still pay
for all the fixed cost of the traditionalmodel of volume driven primary care.
And now looping back to the very beginningof our conversation where you said it
doesn't matter where you are in the caretransformation journey, having care flows,
(26:42):
determining whether also you said, arethese care flows sequential or iterative?
Like really thinking through all of that.
You could do that in a feefor service environment.
Dr. Scott Conard was on the showtalking about how even in a fee for
service environment, he did in factimprove primary care results, and he
had a number of suggestions for howto do that, but even he ran up against
(27:03):
the barrier that you're talking about.
At a certain point, you windup having perverse incentives
that will undermine you.
In the case of Dr. Scott Conard,which is a really interesting podcast,
if anyone didn't listen to it, Iwould encourage you to go back.
Here he was reducing hospital admissions,and you know what the local hospital did?
They bought him and closed him down.
Spoiler alert.
(27:24):
Then at the same time, I'm thinkingto myself when you were talking
about the metformin example,it's a long patient interaction.
Like how long would it take to go throughall the stuff that you were talking about
and create that trust with this patient?
If I've got seven minutes or 15minutes with the patient, this
would be very difficult to achieve.
And if and as a PCP, I'm still tryingto hit my 8,000 RVUs or whatever the
(27:45):
heck it is per year, I just can't evendo these things because just the whole
model of care is set up against me.
Yeah, it really is.
But even so let's think about it evenin a fee for service lens, and I'll
never forget, uh, back when I wasin practice at that multi-specialty
group, one of my partners who was.
Alpha Omega Honor MedicalSociety, finished near the top
(28:07):
of his medical school class.
There was no doubt this physicianwas a really good doctor.
One of his patients happened to endup on my schedule and they were on,
gosh, 25, 30 different medications.
Their blood pressure was really high.
If you don't have an organized wayof how you're going to approach
that patient, it's gonna take youa long time to sort through and
(28:28):
it'll make for a much longer visit.
But what I, at that point,you know, I had a hypertension
algorithm burned into my head.
So I'm going down thislist of medications.
First thing I'm doing is I'm lookingfor either an ACE inhibitor or
an angiotensin receptor blocker.
You know, and like I, I find that.
And then I go down and I findthat the patient was actually
on two different diuretics.
(28:49):
Probably didn't need to beon two different diuretics.
And so, okay, there's someroom for thinking through this.
So for me it's, I'm lookingfor an, an ACE inhibitor or
an antisense receptor blocker.
Then I'm looking for a calciumchannel blocker, probably amlodipine.
Next I might be lookingfor a thiazide diuretic.
This was before a, a trial that justkept published in December of 2021.
(29:10):
But, and this is how the beauty ofthese algorithms in these care pathways.
As new data becomes available, you justmodify the care pathway and you do that.
And you do that for everyone,it ends up being this wonderful,
simplistic way of approaching care.
But like going back to thatpatient who I saw from my partner.
It made it such a quicker, easier visitbecause I was able to just go through
(29:32):
in a very quick sequential manner,quickly jettison a few medications,
add another one, get them on the righthypertension path, and lo and behold,
we get the blood pressure controlled.
That's the beauty of care flows.
It speeds up clinical processing anddecision making and thinking, and then
ultimately where it's gonna go, isanytime you can turn something into
(29:55):
an algorithm, you can indeed digitizeit and then you can create digital
workflows that sort of take someof that work off of the physician.
Which is gonna be necessary becausethere aren't enough hours in the day
for primary care physicians to doall the things they need to do for a
panel of say, 2,500 or 3,000 patients.
I talked with Dr. Beau Raymondon a show about how Ochsner is
(30:18):
starting to digitize are pathways.
Just to underline with six colors,the point that we know how to
deliver amazing primary care.
We know it.
It's just like Dave Chase alwayssays, healthcare is already fixed.
We know how to transform healthcare.
There are solutions available.
We just have to get thosesolutions adopted broadly.
And this is a perfect example of this.
(30:42):
I was thinking as you were talking, sojust my takeaways from what you just said.
If you have a good care flow, thena lot of the cognitive burden is
lifted off of the clinician in thatmoment so that you can use the time
to create trust or do the importantwork of connecting with the patient.
The other thing with the careflow,it's going to enable the clinician to
(31:05):
work with the rest of the team i.e.to make sure that patient actually
shows up for the follow up visit.
There's a lot of other things thatcan happen that spiral around that
clinical visit, which we didn't reallytalk about today, but are obviously
very important for anyone who'sspent 10 minutes trying to do this.
I think what we keep kind of comingback to both the science and the art
(31:26):
of medicine are really important andhave to be present and accounted for.
And standardizing care flows well andmaking sure that we've illustrated what
is possible and there's a culture in theorganization of trying to achieve it.
All of these are essential ingredientsto make sure that the level of care
is consistent across the organizationand as high as it possibly can be.
(31:49):
Dr. Kenny Cole, is there anything thatyou wanna add to this conversation.
I'll add just very briefly,no detail is too small.
For example, in something that youjust said, a careflow is not just,
you start with an angio receptorblocker and an ACE inhibitor, and
then next you add amlodipine, andthen next you add a thiazide diuretic.
A careflow can also include thesimple matter of, you schedule the
(32:12):
patient to come back to get theirblood pressure checked in a few weeks,
but if that patient doesn't showup, if they don't come back, well
that's a huge gap in your care flow.
Your care flow needs toensure that they come back.
And so the way that I first didthis, the very first time I created
something was in the electronicmedical record we were using.
There was a littlebutton called Remind Me.
And so literally I would go upand just click, remind me blood
(32:35):
pressure check in two weeks, orblood pressure check in four weeks.
If the patient came back in four weeks,we would delete the reminder, but if
the patient didn't come back, you wouldput in a date and their name would
essentially turn red, and if their nameturned red, then that just executes a
workflow for the nurse to call 'em andmake sure that they're coming back.
So care flows are very detail orientedand that you're trying to discover
(33:00):
any variable that could potentiallylead to a failure to achieve the
control that you're trying to achieve.
You can do this for blood pressure,for diabetes, for hyperlipidemia,
for you can do it for any one of 'em.
And when you do it wellfor all of them, right?
Because for me it's not abouthaving 95% rate of hypertension
control or 95% diabetes control.
(33:23):
It's about having 95 to a hundred percenthypertension control and 95 to a hundred
percent diabetes control, and 95 to ahundred percent of my patients who have
known vascular disease having theirLDL less than 70, and that they're not
smoking cigarettes, and if they have knownvascular disease that they're on secondary
prevention with antiplatelet therapy.
(33:44):
It's getting all of those ands,and when you get all of those ands
concomitantly, like the percentagethat I'm gonna wanna measure my doctors
and my redesign care models is abundled metric of how often are they
getting all of those things right?
What is that percentage?
That's the percentage we're gonnatry to optimize because if we do,
that's when we're truly gonna impactthe downstream poor health outcomes
(34:06):
of strokes, heart attacks, endstage kidney disease, et cetera.
Once we get to that ideal percentage,that's when we will have achieved
what is truly the art of the possible.
That is very inspiring.
Dr. Kenny Cole, if people areinterested in learning more about your
work, where would you direct them?
I write in these journal articles.
It's nothing prestigious.
It's a local healthcare journal.
I've written about 11 differentarticles in that local healthcare
(34:29):
journal, and a lot of that has manyof the things that we've spoken about.
We will link to them in the show notes.
Dr. Kenny Cole, thank you so much forbeing on Relentless Health Value today.
Thank you.
It was a pleasure being with you.
Hey, this is Matt McQuaidwith Synergy Healthcare.
I listen to Stacey and RelentlessHealth Value every single week.
There's valuable information everysingle week to take from it, and I
(34:50):
just so appreciate this is around.
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