Encore! EP391: A Case Study for Anyone Trying to Level Up Primary Care That I’m Gonna Call “How Margin Shoves Mission Off the Bus,” With Scott Conard, MD
For a full transcript of this episode, click here.
Here’s a great musing that I read on LinkedIn:
How will alternative primary care models fare when growth mode gets balanced with profitability and VC-supported burn rate is transformed to Big Retail bottom-line expectations? Mission v. margin.
I’m gonna add to this: How will alternative primary care models, or even just doing good primary care, fare when it encounters the current system rife with perverse incentives of all kinds, including, yeah, for sure, Big Retail bottom-line expectations but also Big Health System and Big Payer bottom-line expectations and current business models?
This show from last year was wildly popular—maybe one of our most popular shows—and relisten to it in the current context of what’s going on right now in the primary care and MSO (Managed Services Only) space. Coming up, I’m gonna probably do a whole show on this if I can get my act together; but this encore is really relevant right now.
One piece of podcast business before we get into the episode: Please sign up for our weekly email if you haven’t already, especially if you consider yourself part of the Relentless Health Tribe. I am mentioning this not only because it’s a great way to keep track of our shows because you can do an email search to remember where you heard something, since a good deal of the show intros are in the emails, but also, there’s a plan afoot to hold some Zoom meetings to talk about different topics etc—and you won’t be notified of such goings-on unless you’re subscribed. You can unsubscribe whenever you want, by the way; and I am way too busy to send more than one email a week or spam if that was a concern.
On Relentless Health Value, I don’t often get into our guests’ personal histories. There are a bunch of reasons for this, which, if you buy me beer, we can talk podcast philosophy and I will tell you all about my personal, very arguable opinion here.
Nevertheless, in this healthcare podcast, we are going rogue; and I am talking with Scott Conard, MD, who shares his personal story. You may ask why I decided to go this route for this particular episode, and I will tell you point-blank that Dr. Conard’s experience, his narrative, is like the perfect analogue (Is analogue the right word [allegory, composite example]?). His story just sums up in a nutshell what happens when a PCP (primary care provider) does the right thing, manages to improve patient care for real, and then at some point gets sucked into the intrigue and gambits and maneuvering that is, sadly, the business of healthcare in the United States today.
Before we kick in, I just want to highlight a statement that Scott Conard makes toward the end of the show. He says:
So, this isn’t about punishing or blaming aspects of care that are being overrewarded today. It’s really about what’s the path forward for corporations, for middle-class Americans, and for primary care doctors who don’t choose to be part of a big system.
We have to figure out how to solve this problem. I hope people don’t hear this and think that there are horrible people at some not-for-profit hospital systems, for example. There are some great people at not-for-profit health systems, but they have some really screwed-up incentives.
A few notable notes from Dr. Scott Conard’s journey and words of wisdom that I will just highlight up front here:
He says that as a PCP, you actually can produce high-value care in a fee-for-service model … if you think differently and you change practice patterns. I have heard this from others as well, including most recently David Muhlestein, PhD, JD, who says this in an episode (EP393). As Dr. Scott Conard says later in this episode, healthcare organizations must embrace the art of medical leadership. So, I guess that’s a spoiler alert there.
Another point that Dr. Conard makes very crisply toward the end of the show is that doctors can kinda get pushed and pulled around in this mix. You have docs just trying to provide good care, and they work for one entity that gets bought and now it’s some other entity … and what’s happening upstairs and the prices being charged or somebody somewhere deciding not to make prices transparent, or deciding to sue low-income patients for unpaid medical bills or what charity care to offer or not to offer. These are not doctors in clinics making these calls, and we need to be careful here not to homogenize what some of these health systems are choosing to do like some kind of democratic vote was taken by everybody who works there. Health systems, hospitals, are many-celled complex entities.
And a third takeaway—there are a bunch of takeaways in this show, but a third one I’ll highlight here from Dr. Conard’s story—is the old fiduciary responsibility code word being used by health system administrators as a euphemism for strategies that might need a euphemistic code word because the strategy has questionable community benefit.
In the case study that we talk about today, the local health system managed to raise healthcare spend in North Texas by $100 million year over year. Employers and employees in North Texas communities wound up paying $100 million more year over year in healthcare one particular year.
This was prices going up. It also was removing a big systemic initiative to keep heads out of hospital beds. Reiterating here, we are not talking about doctors here particularly because, of course, the vast majority of doctors are trying to prevent avoidable hospitalizations. But suddenly in North Texas, physicians did not have the population health efforts and the team really standing behind them helping to prevent avoidable hospitalizations.
That sucks for everybody trying to do the right thing, and, as has been said, burnout is moral injury in a cheap Halloween costume. Moral injury happens when you have good people, clinicians, doctors, and others who realize that what is going on, at best, is not helping the patient.
Also mentioned in this episode are Benjamin Schwartz, MD, MBA; David Muhlestein, PhD, JD; Brian Klepper, PhD; Al Lewis; Robert Pearl, MD; Karen Root, MBA, CCXP; and Wendell Potter.
You can learn more by emailing Dr. Conard at [email protected].
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