Primary Care: Are You Busy Or Effective (or Both)?

May of 2018 we turned on dashboards on the Value of Care for a group of 400 providers. On the dashboard the scale of 0 – 100, a 70 was considered “good value,” below this there were significant opportunity for higher value care. The average score for our providers was 35.

Within hours the phones began to ring – “my care is better than this,” “my dashboard is wrong,” “your data is incomplete” – the general sentiment was “I am making a bigger difference that you are saying I am.”

Let’s look at the facts – they were busy – usually filling their schedule to 80+%, moving through the day giving 100% to each person sitting before them. At the end of the day going home feeling tired but sure of their contribution to their patients. They must be high quality, effective, and their patients are benefiting based on days, months, and years of committed work.

So why the relatively low scores? We set up teams to investigate. The ability to click down to a member level allowed the providers to see what was going on with their patients. Were the patient really theirs or not? An examination revealed YES! Then why weren’t their blood pressure, cholesterol, asthma, blood sugars, immunizations, and screenings not at goal?

Barbara was supposed to come back in but never did, Bob travels all the time, Suzie stopped taking her meds, but never communicated it, John’s son got ill and he missed his appointment and never came back in…. The list of reasons went on and on. But the reality did not change – we were confusing being busy with meeting the needs of our patients. Often, we were not seeing the patients that needed us the most.

This lead to new systems, new ways of proactive (and automated) outreach. Soon the right patients were in the right practice at the right time. Quality took a jump up. Providers knew they were doing the best thing for all of their patients, not just the ones in front of them.

Busy was now productive and we were adding years to the lives and life to the years of those we served!

Is your practice busy, effective, or both?

Will IBM save the US Middle Class?

By DrScott – Posted on March 9, 2106

When I read the news of IBM’s acquisition of Truven Analytics last week I had to contain my excitement.  From my perspective, it is ground shaking to imagine the potency of IBM Watson Health gaining access to a significant cache of private and public healthcare data.  Let me explain.

The middle class in America has been under significant economic pressure from the impact of healthcare costs for years.  For well over a decade the significant gap between increases in income and increases in health care expenditures continues to widen. This is particularly important for those making less than $75K annually, where every dollar of disposable income impacts the quality of life.  In addition, it is commonly reported that medical bills are the #1 cause of bankruptcies, with a disproportional impact on the middle and lower classes.

Adding to this is the shift toward consumerism with strategies like high deductible plans, which increase the proportion of health care cost burdens on the individual. Consequences include higher individual costs and lower compliance with prescribed medications and interaction with the healthcare system.  These current circumstances are thus aggravating the problem pointed out by the Institute of Medicine in its landmark 2004 Crossing the Chasm report which concluded “we know what to do (medically), but are not doing what we know.”  This too targets those with the lowest ability to absorb the increased expense – the middle and lower classes.

These lower adherence rates notably affect primary (lifestyle & immunizations), secondary (pre-disease), and tertiary (disease) prevention efforts, where “doing what we know” has the potential to decrease the development, progression, and complications of disease, thereby saving billions of dollars, pain and suffering. Successfully accomplishing this would save individuals from needless cost, disease, disability and death – adding to the prosperity and productivity of the middle class.

So what does this have to do with IBM?  With the acquisition of Truven, coupled with the insight Watson Health can provide IBM in predictive analytics, and the addition of Phytel (more below), IBM can literally transform healthcare in America from the antiquated, dangerous, fragmented “system” we have now to the proactive, effective, life-enhancing, possibility.  Seem impossible?  Here’s how they’ll do it.

When IBM loads the Truven database into Watson, the world of “Watson Age” of predictive analytics will continue to evolve.  The relatively primitive use of “gaps in care” and the actuarial models that predominate today will be replaced by the ability to predict events and health changes not possible in the past.  Made available to individuals or groups of individuals, say a corporation, Medicaid, or Medicare recipients, informed individuals with the knowledge and confidence to choose, can reduce unnecessary conditions, cost, pain & suffering, disability, and death over a relatively short time (months to years).

If programs and systems were designed and taken to individuals in apps and programs; and if the incentives in health plan benefit design, whether government or private, were created to support individuals successfully achieving these recommendations, then the US Healthcare system could pivot from the most expensive, and one of the less effective systems to the highest value system in a matter of years. This would save literally billions of dollars in unnecessary care, unintended consequences of the care provided, and the provision of important care that remains undone in America today – a huge benefit to all Americans, and to the middle class particularly.

In addition, the ability to look at individual doctors, integrated delivery systems (IDNs), and accountable care organizations (ACO’s) with statistical power and new insights will be unparalleled in history.  Why is this so important?

Imagine for a moment that every doctor, IDN, and ACO had insight into their value to the system along the lines of quality, safety and cost.  While this initially may be disconcerting to the average doctor or health system, done properly, this information would be used to improve individual and organizational effectiveness, and potentially over time, to weed out those providers who are unwilling to meet acceptable benchmarks.  A necessary change to the #3 cause of death: the US healthcare system.

Over time these analyses would be made public to individuals who would then have the ability to factor in quality, cost, service, and safety into their healthcare decisions, finally making transparency a reality that empowers the individual healthcare consumer.

Also, don’t underestimate the power of the demographics embedded in the Truven database.  The ability to analyze and predict who will be compliant and adherent to healthcare recommendations, and to generate hypotheses and research to improve engagement and activation are also important.  Patient/employee engagement has been characterized as the “next billion dollar drug” and this lays the foundation for IBM to raise the stakes and effectiveness in this vital area.

IBM’s acquisition of Phytel a few months ago plays directly into this strategy with its proven effectiveness in providing individuals and providers with important information to improve and proactively manage their health, providing another crucial link in the chain of critical steps to transform healthcare.

From my perspective IBM’s strategy will work.  As a primary care doctor who struggled with proactive healthcare, I have seen the power of effective analytics when working with Jim May of Clinical Integration of North America (CINA); of effective outreach while working with Neil Smiley the founder of Phytel; linked to effective implementation in a primary care practice serving patients in north Texas (TienaHealth).  This was early in the 21st Century so it took a few years to design, but the resulting increase in effectiveness, efficiency, and patient satisfaction, the Triple Aim, were inspiring.

While this vision might sound naive or optimistic, it is possible.  The combination of Truven’s data and Watson’s insights creates the possibility of a new future that could result in an infusion of billions of dollars of discretionary income into the middle class.  While not solving the problem of job creation, education, healthier communities, and the other challenges facing the middle class today, it certainly would be a huge step in the right direction.

An Invitation To Join A Journey To Next Level Healthcare Leadership

By DrScott – Posted on March 11, 2015: You already know healthcare is in a time of tremendous transition.

The Question is what role will you play in this change?  How will you skillfully navigate these waters as a leader in your organization or system?  How will you win or lose in the next 3, 5, and 10 years?

Without question your organization will realize greater success if you are prepared to lead.  The greater your capacity, the greater your success will be – from revenue to influence.

How prepared are you to lead?  Do you have a comprehensive, cohesive and integral skill set that allows you to navigate and lead a team through the challenges coming at you today, and will it expand as your role grows?

We are looking for a select group of leaders who want to play a key role for their companies and for the country in this transformation.  The format will be an interactive, collegial exploration of your personal skills in the context of learning proven and transformational leadership skills for groups, corporations, and systems.  This course is for lifelong learners who want to take themselves to the next level.

If you would be interested in learning more please contact us at and/or consider joining us Tuesday, May 26, 2015 for lunch at the Stagen Leadership – the PDF brochure on this course is attached below.

Again, please RSVP to

ILP Informational Session

When: Tuesday, May 26th


Where: 3535 Travis St. | Suite 100 Dallas, TX 75204

*Parking is available underneath the building.

Stagen ILP – February ‘Osler’ Class

Here’s to a great future for every person accessing the US Healthcare System – and here’s to the leaders who are going to make it happen.  Hope to see or hear from you soon.

Scott Conard, MD

Course Co-leader

Stagen ILP – Osler Class


Forbes Reports States Fail on Transparency – How Are You Doing?


By DrScott – Posted on March 27, 2014 on

Transparency transforms employee’s relationship with health care. Actionable data delivered in a way that allows informed decision making has the potential to save tens of millions for both organizations and individuals at risk for health benefit expenditures.

The Accountable Care Act requires making transparency information more available and actionable for the public. This article points out that our states have not navigated this challenge successfully – yet. As Suzanne Delbanco executive director for Catalyst for Payment Reform states, “As much discussion and activity as there is around transparency, the truth is that today it’s a very rare instance when a consumer can easily find meaningful information about health care prices. We’ve got a long way to go.”

The challenge is even bigger than this article acknowledges. In order to go from an F to an A in the state transparency ratings, all that had to occur was for the data to be put on a web site. As the article states “In order to get a good grade, the groups say a state needs to provide public access to a “fully functioning website” as well as ensure regulations on price information are accessible for a long period of time.”

Engagement data suggests that having access to a web portal is only a beginning. Translating the web information into action often requires human support and interpretation. The moment questions like “is the MRI with or without contrast” are asked, many users are stumped and abandon their transparency exercise.

Avoiding the #3 Cause of Death in the USA: US Hospitals & What You Need To Know About It – Part 2

The gauntlet had been laid.  Don Berwick and the Institute for Healthcare Improvement (IHI) had challenged hospitals in America to save 100,000 lives.  Time was ticking away, educational programs, mentoring, training had begun but would they achieve the goal?

Eighteen months later on June 14th 2006 at 9 a.m. – Dr. Berwick took the stage to announce the results: “Hospitals enrolled in the 100,000 Lives Campaign have collectively prevented an estimated 122,300 avoidable deaths and, as importantly, have begun to institutionalize the new standards of care that will continue to save lives and improve health outcomes into the future.”

But that was only the beginning.  Remember, if there are 5,723 registered hospitals in the US, this initiative got 2,300 of them to commit in the first few months.  By the end of the campaign 3,100 hospitals had enlisted.  But thousands of Americans were still dying in US hospitals from preventable causes each month.  So the IHI moved the goal – in December 2006, IHI launched a second, expanded effort, the Five Million Lives campaign.   At its formal close in December 2008, the Campaign celebrated the enrollment of 4,050 hospitals, with more than 2,000 facilities pursuing each of the Campaign’s 12 interventions to reduce infection, surgical complication, medication errors, and other forms of unreliable care in facilities. Eight states enrolled 100% of their hospitals in the Campaign, and 18 states enrolled over 90% of their hospitals in the Campaign.

In 2011 the Secretary of the Department of Health and Human Services Kathleen Sebelius and Dr. Berwick launched the Partnership for Patients, which brings together hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in an effort to make hospital care safer, more reliable, and less costly.  The Partnership for Patients aimed to decrease preventable hospital-acquired conditions by 40 percent by the end of 2013, resulting in approximately 1.8 million fewer injuries to patients and more than 60,000 lives saved over the next three years. It also sought to reduce hospital readmissions by 20 percent by decreasing the rate of preventable complications during transitions from one care setting to another. The Partnership was to be funded by up to $1 billion in federal money made available under the Patient Protection and Affordable Care Act, including $500 million through the Community-Based Care Transitions Program and up to $500 million through the Centers for Medicare and Medicaid Innovation.    At the core of this initiative are 26 Hospital Engagement Networks, with 3,700 hospitals, working with health care providers and institutions to identify best practices and solutions to reduce hospital acquired conditions and readmissions.  Early results are showing strong progress in 8 of the 10 patient safety priority areas of the Partnership for Patients, more findings are scheduled to be released soon.

But recall that only 3,700 of the 5,723 hospitals in the US are engaged, meaning that over 2,000 hospitals are not on board and thousands of Americans are still suffering unnecessarily.  And recognize that this is looking at the prevention of adverse events, not at which institutions are the best at different procedures.  The best spine hospital may not be (and often isn’t) the best heart surgery facility in your community.

So how do you find the right hospital?  It takes research and time. It also takes a willingness to sift through a lot of different data to tease out what information would be important to you. Let’s think through a visit to the hospital – the quality of the health care a patient receives depends on many things besides the skill of the surgeon. Many health care providers at a hospital will be directly involved in care before, during, and after surgery. The metrics a patient will want to know span a broad spectrum of considerations, from scientific data on mortality and complications associated with previous treatment of patients with the same condition to the more subjective data on how patients respond to the physician and staff managing their care.

A result of this complexity in defining a good hospital is the proliferation of information sites that exist. In addition to the payers websites (carriers who are often dependent on contracting agreements with the hospitals), patients can go to anything from and Angie’s List (which also provide reviews on low complexity services like dry cleaning), to state report card sites or national sites such as Hospital Compare which may or may not have information on metrics associated with your condition. For heavier science aficionados, there are reporting agencies like CareChecks and The Dartmouth Atlas which may look at patient outcomes on a larger system level. Reports are also often put out by institutions such as the Kaiser Foundation or Commonwealth Fund that speak to hospital quality.  Somewhere in the middle of this very complex gamut are sites like Vitals or Health Grades. More traditional outlets such as Consumer Reports or the US News & World Report create hospital listings as well.

But it is not just the hospital.  The doctor and the care team he or she works with make a significant difference.  In the next blog we will consider how to find and use these “best in class” doctors.

Avoiding the #3 Cause of Death in the USA: US Hospitals & What You Need To Know About It – Part 1

By DrScott – Posted on March 18, 2014 on

Preventable Adverse Events (PAE’s) are the #3 cause of death in the US, leading to between 210,000 and 440,000 American deaths annually.  This must stop.  But how?  The answer involves one of the best stories in US healthcare history.

It started when Dr. Donald Berwick, the co-founder, president and CEO of the Cambridge-based Institute for Healthcare Improvement (IHI), was driving with his son, Dan to the airport.  Dan, a political campaign strategist, explained that he was bringing 350 volunteers to Florida for a weekend to knock on 50,000 doors for his candidate.

Awed by the numbers, Berwick, 57 at the time and a clinical Professor of Pediatrics and Health Care Policy at Harvard, shared IHI’s frustration about the slow pace of change in medicine when it came to adopting practices known to improve care and reduce errors.  As the former head of quality-of-care measurement for a large HMO, Berwick knew the numbers: As many as 98,000 American hospital patients die annually from poor care or medical errors. IHI researchers estimate that approximately 15 million incidents of medical harm occur in U.S. hospitals annually, roughly 40,000 every single day.

So, Berwick asked his son the critical question: “What makes your work so effective?” Dan explained what it takes to run a successful political campaign – coming up with concrete numbers (i.e. how many people you want to reach), establishing field offices to reach more people locally, inviting the widest possible participation, giving specific instructions to workers, and setting a deadline.

The IHI  only had 75 people on staff at the time and no way to mount the national campaign needed to create any significant change, or did they?  On December 14th 2004, Dr. Berwick gave a speech to a room full of hospital administrators.  He said, “Here is what I think we should do.  I think we should save 100,000 lives.  And I think we should do that by June 14, 2006 – 18 months from today.  Some is not a number; soon is not a time.  Here’s the number: 100,000.  Here’s the time: June 14, 2006.”

To accomplish this the IHI proposed six specific interventions for hospitals to adopt that had been proven to reduce unnecessary deaths.  If you have been reading the blogs on the book Switch by Dan and Chip Heath, you will appreciate that the “rider” now has a clearly defined goal to achieve.

But this was a challenge for hospitals to embrace and get behind.  If they did embrace it, it implied that unnecessary deaths were occurring in their hospitals.  So, Dr. Berwick made it personal.  At his speech he asked the mother of a girl who had been killed by a medical error to join him.  She said, “I’m a little speechless, and I’m a little sad, because I know that if this campaign had been in place four or five years ago, that Josie would be fine….  But, I’m happy, and thrilled to be a part of this, because I know you can do it, because you have to do it.”  Another guest on the stage, the North Carolina State Hospital Association Chair, then spoke up: “An awful lot of people for a long time have had their heads in the sand on this issue, and it’s time to do the right thing.  It’s as simple as that.”  (Switch: the elephant was motivated).

The IHI made joining the campaign easy; hospital CEO’s only had to sign a one page form.  Once a hospital enrolled, the IHI team helped them embrace the new interventions.  Research, step by step instructions guide and training were provided, and regular teleconferences with the hospital leaders to share their victories and struggles were arranged.  Hospitals with early successes were encouraged to become mentors of hospitals who joined the campaign later. (Switch: the path had been made easy).

But would they achieve the goal? Eliminating errors and documenting the results had never been done this way in the US Healthcare system. As a patient, the challenge of finding an excellent facility and doctor to use can be daunting.

Will You Die from the #3 Cause of Death in the USA?


By DrScott – Posted on March 13, 2014 on

In the 2013 September edition of Journal of Patient Safety Article Asks: Will You Die from the #3 Cause of Death in the USA?

Ask most people what the #1 & #2 causes of death are and they will usually know they are heart disease and cancer. Ask them for the #3 cause and you are likely to hear infections, trauma, or pneumonia but few guess American Healthcare.

But the correct answer is the Hospitals in the US. The Journal of Patient Safety in September of 2013 revealed that between 210,000 and 440,000 people die from hospitalizations in the US each year. Here’s how they come to this conclusion:

To begin, it is important to understand the concept of preventable adverse events (PAE’s). These are unexpected and harmful experiences that occur because high quality, evidence-based medical care was not delivered during hospitalization. PAE’s can be:

  • Immediate – a side effect of a drug, or
  • Delayed for months – contracting hepatitis from dirty needles a few months after hospitalization, or
  • Delayed for years – getting pneumonia because a pneumonia vaccination was not given to a patient receiving a splenectomy years prior.

PAE’s are further categorized into:

  1. Errors of Commission – the wrong action or right action performed incorrectly on a patient.
  2. Errors of Omission – an action needed by a patient was not performed; for instance, a medicine was indicated but not given in a vital situation.
  3. Errors of Communication – for example, two providers failing to communicate clear instructions during surgery; or a provider and patient inadequately reaching an understanding of discharge instructions.
  4. Errors of Context – an example is when a patient is discharged but is unable due to cognitive ability, to perform tasks needed for their safety.
  5. Diagnostic Errors – resulting in delayed, incorrect, or ineffective treatment such as mis-identifying a tumor biopsy as benign when it is actually malignant.

To identify these PAE’s, a systematic review of medical records was performed at hospitals by trained personnel with the Global Trigger Tool (GTT), developed by the Institute for Healthcare Improvement (IHI). The results were then validated by one or more physicians. Four studies with a total of 4,252 records revealed 38 total deaths associated with adverse events. The ratio equates to a death rate from adverse events of 0.89%.

As previously referenced, the September 2013 The Journal of Patient Safety article indicated that there were an estimated 34.4 million hospital discharges in 2007, and the average percentage of preventable adverse events was reported at 69%. Thus, the best estimate from combining these 4 studies is 34.4M discharges × 69% with PAEs × .89% death rate = 210,000 preventable adverse events per year that contribute to the death of hospitalized patients.

According to the Center for Disease Controldeath statistics in the US are:

  1. Heart disease: 597,689
  2. Cancer: 574,743
  3. Chronic lower respiratory diseases: 138,080
  4. Stroke (cerebrovascular diseases): 129,476
  5. Accidents (unintentional injuries): 120,859

As you can see, 210,000 deaths puts US Healthcare squarely in the #3 position for annual cause of death.

But even this may be an underestimate.

This conclusion is based only upon medical records. This fails to account for confounders such as poor documentation, complications managed by non-hospital facilities or in the outpatient setting, the “wall of silence” of health professionals altering or omitting critical data when mistakes occur, and the fact some medical errors are not known by clinicians and only come to light during autopsies (rarely performed), to name a few. Thus the actual number of deaths is significantly underestimated by at least 50%, based upon chart reviews, given the high probability of these confounders. The Journal Article therefore estimates the actual number of deaths is closer to 440,000 deaths per year, making medical inpatient errors the number three cause of death in the US by a significant margin.

A scary conclusion to say the least. What can be done to protect ourselves, and our employees, from this challenge? Join us for next week’s blog.

It is Time to Bend the Healthcare Cost Curve & Receive Higher Quality Care

By DrScott – Posted on March 11, 2014 on

Companies in America spend billions of dollars on medical care expecting high value, safe and evidence based care. But are they getting it? Transparency data suggests they are not. Specific areas being questioned include:

  1. Are patients getting too much care? How can employers and employees minimize excess care?
  2. Is 30% to 50% of the care delivered worthless? How do we avoid these costs and reduce healthcare spend dramatically?
  3. Is US Healthcare really the #3 cause of death behind heart disease and cancer? How can employers and employees avoid being killed by American Healthcare?
  4. Do up to 80% of bills submitted to insurance companies contain errors, requiring time, energy and money for employees to correct? How can employees avoid paying incorrect bills?
  5. Are employees actually being driven into bankruptcy due to the medical care they are receiving? How can employers protect their employees from the time, energy and distraction of huge, and at times inappropriate, financial challenges from health care bills?

Asked another way: Are employers paying billions for often inappropriate, misguided and expensive care?

What can be done to reverse this trend and to protect the employees and the financial bottom line?

In the next weeks we will explore these questions and discover how Don Berwick and the Institute for Healthcare Improvement (IHI) inspired hospitals to save over 100,000 lives in 18 months. We will also discover how to avoid paying 300% more for tests and services, how to protect yourself from incorrect billing practices, and how to avoid being hassled and bankrupted by the medical industrial complex.

One key is to make sure your employees are seeing the best providers.

Switching Employees On: Using Video to Entertain, Engage, and Educate

By DrScott – Posted on March 4, 2014 on

Third in the Switching Employees On: Using Video to Entertain, Engage, and Educate Series

Truck drivers can’t watch videos while they drive! So one company’s president created a series of short 3 minute audios to educate and entertain his drivers while they drive throughout the US. This creative, educational, and motivational series follows all three of the major themes laid out in Switch, How to Change Things When Change is Hard by Dan and Chip Health. The rider is directed to take the next “baby steps” for health, the elephant is motivated with emotional stories – some funny, others tragic, and the path is made clear to stop by the onsite clinic, contact the Health Pro, and follow the other simple steps to qualify for the “I Care” health plan. Listen to the audio done by one president here.

Switching Employees On: Using Video to Entertain, Engage, and Educate

By DrScott – Posted on February 27, 2014 on

Second in the Switching Employees On: Using Video to Entertain, Engage, and Educate Series

Heart disease is the #1 killer of Americans. The problem is that we often “feel fine” until it is too late – 50% of men and 66% of women die the first time they feel chest pain, according to the American Heart Association. To “turn the elephant” toward a new path away from unnecessary heart attacks and strokes to a long vital life requires creative interventions. In this video all three principles from Switch, How to Change Things When Change is Hard by Dan and Chip Health are addressed.

  1. The rider is directed to “get your biometrics and screening done even though you feel fine”.
  2. The elephant is motivated because “wonderful people who ‘felt fine’ did not get to be there for their spouse and children”.
  3. The path to better care is made clear by “contacting your Health Pro if you do not know what tests are recommended for you, or you need a high quality doctor.”

Using this and other tools this employer has been able to increase annual physicals among its insured members over time. Watch the video here

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