Optimizing Metformin Treatment for Type 2 Diabetes: Managing Care Variability

For a full transcript of this episode, click here.

There’s this meme that’s going around on the interwebs with the caption, “Sometimes the shortest distance in between two places isn’t a straight line.” What? Yeah, because actually there’s three dimensions in the real world.

So, when we all consider the real world, understanding the contours of reality and aligning with them is the only way to devise a winning strategy—not only if you’re timing rubber balls getting dropped off straight or curved slopes. I’m saying this because I’ve seen (and you’ve seen) a whole lot of great ideas fail because someone draws a very elegant straight line on a whiteboard, calls it the fastest and most efficient way to get from here to a desired outcome … and then the plan ultimately fails.

What contours am I talking about taking into account right now? Oh, pretty much the entirety of US healthcare. If you combine the complexities and perverse incentives of the industry itself plus the art and science of medicine plus epidemiology and social determinants and I’m probably forgetting other dimensions, you have contours that are mountain ranges. Not considering the reality of those elevations and just thinking there’s some kind of straight line here to be found is really a kind of delusion. Now, investors and C-suites may like these delusions, but let’s just get real: It’s not gonna actually work out as written.

One case study that I am talking about is digital health solutions or pharma companies even or pretty much anyone who thinks that the fastest way to increase sales is to talk about the product, let’s just say as one example. That’s the straight line to growth: Talk about the product. Another one is stripping away things that feel like they’re a waste of time in the name of efficiency without actually checking if you’re cutting into essential stuff. I talk about this at length with Kate Wolin, ScD, in an episode coming up. Jodilyn Owen has a thing or two to say on this point in episode 421 also.

But let me be clear: I’m not talking about anyone listening to the show today making this mistake, at least wholesale. We all make it incrementally; it’s hard to avoid. But you get this. That’s why you’re here.

You get that the fastest path anywhere is truly understanding the problems faced by customers. And then it’s showing how the product or whatever you’re doing helps solve those problems. No one cares how efficient or safe your thing is if it’s accomplishing something that no one cares about, no one gets paid for, and/or can figure out how to deploy or use. This is what the entire episode last week, episode 430 with Barbara Wachsman, was about.

Why is all of this relevant? It’s actually what makes Relentless Health Value relevant, frankly.

Many listeners—and shout-outs to Nate Walker and MaryCarol Evans—say that this is why they listen to Relentless Health Value and what Relentless Health Value helps them with: finding those contours, understanding reality so that it can be aligned with. And on the show today, Kenny Cole, MD, I gotta say, could be really impactful in this regard as well as in others.

Nate Walker wrote, “[Relentless Health Value] inspires me every day to stay true to my desire to make a difference in healthcare for patients by adding transparency and helping to connect the dots within this fragmented system.”

MaryCarol Evans has alluded to the same thing multiple times as well and often highlights that Relentless Health Value helps her think through and identify the small things that are possible—she says there’s plenty of them—that have a huge impact on the lives of plan members.

Dr. Kenny Cole is from Ochsner Health System, and I love this conversation today because it has lessons for anybody working in a clinic or managing a clinic who wants to learn from a master. But it also is really interesting for anyone who’s trying to work with, alongside of, or sell to a clinical practice or health system that is pulling away from the status quo, that is standardizing care and working as a team, one that is earning the trust of its patients, and also one that is figuring out how to reinvent the business model of healthcare such that clinical pathways and care flows are aligned with financial viability. That’s really, obviously, the holy grail here.

We talk today about how to achieve clinical and financial success, even if the financial models are all over the map. We talk about how to create a practice model or a clinical model that might appeal to clinicians and keep them from being burnt out while, at the same time, ensure that patients are getting the kind of outcomes everyone can be proud of and the place doesn’t go bankrupt either.

This episode reminded me a lot of the conversation with Scott Conard, MD (EP391)—there’s lots of complementary points. The shows with David Carmouche, MD (EP316, AEE15, EP343) from when he was at Ochsner are also pretty relevant here. Some of the points that Dr. Kenny Cole makes today also align very much with what Rik Renard (EP427) was talking about a few weeks ago.

But regardless of where you sit or what you’re trying to do, this show is a great one to really get a bead on the lay of the land to find the actual shortest path between here and there, which is not gonna be (most likely) an obviously straight line.

Dr. Kenny Cole makes, I’m gonna say, four main points by my counting; and they are as follows:

1. Clinical teams have to deliver care wherein outcomes are measurable, and it has to be done in such a way that those clinical teams are accountable for the outcomes that are generated.

2. Clinical teams need to really see with their own two eyes and believe that a clinical goal that they’ve been given is possible.

3. Care flows are critical here, which means getting everyone on the same page about what best-practice care looks like and operationalizing how that clinical excellence will be achieved.

4. Building trust with patients and connecting with patients cannot be underestimated, and care flows need to not only standardize care so that it can be delivered quicker and easier but also facilitate patient relationships.

Dr. Kenny Cole is a primary care internist. He sees patients one day a week. The other days, he serves as a system vice president for Ochsner Health, which is a large integrated delivery system. In this role, he designs and develops new care models.

If I’m making recommendations for what to listen to next, I’d go with episode 412 with Robert Pearl, MD—he talks about a model to lead healthcare transformation and clinical excellence. Then episode 391 with Dr. Scott Conard gets into what happens in the real world when the financial model is misaligned with excellent care. Lastly, episode 343 with Dr. David Carmouche.

Oh, two last things and new topics:

First, thanks to Santos-L-Halper, Nina Lathia, and KC64789 for some really nice reviews this month. I read them. They make me happy. Thanks so much for leaving them.

And lastly, heads up that Rule of Three (ro3) has an annual March Healthcare Classic that is currently ongoing. It’s pretty cool what they do. They have a very august panel that debates which trends will reign supreme in their impact on healthcare in 2024. The committee includes:

·      Dr. David Carmouche, SVP Healthcare Delivery, Walmart Health

·      Eric Gallagher, CEO, Ochsner Health Network

·      Leah Binder, CEO, The Leapfrog Group

·      Anisha Sood, Chief Financial & Strategy Officer, First Choice Health

Follow along with the experts through the ro3 March Healthcare Classic at https://ro3.com/healthcare-classic/.

Also mentioned in this episode are Jodilyn Owen; Barbara Wachsman; Nate Walker; MaryCarol Evans; Scott Conard, MD; David Carmouche, MD; Rik Renard; Robert Pearl, MD; Nina Lathia, RPh, MSc, PhD; Josh M. Berlin; Rule of Three, LLC; Eric Gallagher; Leah Binder; Anisha Sood; John Rodis, MD, MBA, FACHE, CPHQ; Bob Matthews; Marty Makary, MD, MPH; Sanat Dixit, MD, MBA, FACS; and Rob Andrews.

You can learn more at Ochsner Health. You can also follow Dr. Cole on LinkedIn.

Kenny Cole, MD, began his role as System VP, Clinical Improvement, for Ochsner Health in New Orleans in September 2019. He is a practicing primary care internist with advanced degrees from LSU Health Sciences Center and Dartmouth, as well as executive training from Harvard Business School. Prior to joining Ochsner Health, Dr. Cole was the chief clinical transformation officer for Baton Rouge General Medical Center, where he designed, developed, and implemented a completely reimagined multidisciplinary team-based model of primary care that focused on aligning clinical with financial outcomes. His current work at Ochsner Health built on that prior foundation to design and help develop Ochsner 65 Plus, a group of redesigned primary care clinics focused on the needs of older adults.

07:38 Is there an optimal care pathway where there might be a lot of treatment variability?

11:01 Why doesn’t Dr. Cole like the terms “noncompliant” and “nonadherent”?

11:45 EP412 with Robert Pearl, MD.

13:50 Why is it important to start with the end in mind?

17:20 How do you scale clinical excellence?

20:21 EP315 with Bob Matthews.

21:15 EP242 with Marty Makary, MD.

23:49 Why is it important simply to demonstrate what’s possible for better health outcomes?

24:58 EP427 with Rik Renard.

26:10 How do we reinvent the business model of healthcare?

27:50 EP415 with Rob Andrews.

30:06 EP391 with Scott Conard, MD.

38:37 Dr. Cole is published in various healthcare journals; check out his most recent article.

You can learn more at Ochsner Health. You can also follow Dr. Cole on LinkedIn.

Kenny Cole, MD, discusses #accountability for #healthoutcomes on our #healthcarepodcast. #healthcare #podcast #digitalhealth #healthcareleadership #healthcaretransformation #healthcareinnovation

Recent past interviews:

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Barbara Wachsman, Luke Slindee, Julie Selesnick, Rik Renard, AJ Loiacono (Encore! EP379), Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse