Relentless Health Value‪™‬ Stacey Richter

Just taking a moment here to thank our Relentless Tribe for really getting yourselves involved in the work that I had originally kicked off to improve the outcomes for CKD (chronic kidney disease) patients in this country.
With the momentum that we have so far, this Relentless Tribe of ours, we are really (for reals) going to produce measurable improvements for patients with CKD—so many of you, not just talking but actually out there, actively doing what you need to do so that patients do better, and it’s making a difference.
I have talked to doctors, other clinicians, administrators, IPAs, other provider organizations big and small, payers, societies, a great data company, a number of you who are consultants. It’s crazy what we have been able to build so far, and we’ve been doing this for less than a year. The Relentless Tribe … let me tell you, we move mountains.
We get patients properly diagnosed. We get them into appropriate treatment plans. What restores my faith in these rough times, we have encountered one PCP, one clinician after another; and the second that we show them the “as per the guidelines” way to accurately diagnose and stage chronic kidney disease (which is not just using eGFR for those clinicians who might be listening), yeah, that’s it! These are great doctors, and they switch it up. They switch up what they are doing, and that makes my heart warm. These are doctors across the board, from ones in independent practices to ones maybe employed by academic medical centers. And once they have the right information, they use it.
And it’s a wonderful thing, and I cannot thank everybody who has contributed enough. We are making real differences in patients’ lives. If what I am doing speaks to you in any way, please hit me up, because we’re cooking with gas and I could not be prouder of this community of change agents that we have built here.
You’re amazing. You know what needs to be done, and you’re not afraid to do it.
Now, back to our regularly scheduled programming. In this healthcare podcast, I am talking with Secretary David Shulkin, MD, and Erin Mistry. Here’s the first reason why I was interested in taking this interview after their public relations firm contacted me. We were at the thINc360 conference in DC earlier this summer, and I heard them talking about patients on dialysis dying from infections, which … didn’t realize how common that was and it seemed like a nice adjacency to our ongoing CKD work.
I also thought this might be an opportunity to learn a little bit more about what’s going on with hospital-acquired infections and infection control. Superbugs are hella scary, but one thing I’m just gonna point out—and, small sidebar here, but listen to the show with Bruce Rector, MD (EP300) for more on this—in recent times, I don’t think there has been a pharma company who has managed to launch an antibiotic and achieve commercial success. So, what can easily wind up happening under the current payment model is that instead of just using the new antibiotic to treat resistant cases, there’s this perverse incentive to push for the drug’s use more broadly because more prescriptions, more money. But when the new antibiotic is used more broadly, that actually reduces its effectiveness against those resistant infections that it is here to treat.
Okay … back to bloodstream infections now, which is the topic of the conversation today. If a patient has a central line infection and then gets sepsis, their chances of readmission within 30 days is almost 99%. This is not a little cohort. It’s not small potatoes we’re talking about here either. As Secretary Shulkin says during this interview that follows, if you’re gonna make a preventative care economic case study, do it on hospital-acquired infections and, most particularly, those with central lines that lead to sepsis. Even with very short time horizons, you can make that case.
So, that was two reason

I decided to encore this episode with Carly Eckert, MD, PhD(c), MPH, because I keep finding myself quoting Dr. Eckert in conversations, even a year later.
First off, if you’re not familiar, a care gap is what happens when there is a bad transition of care. Patient has no idea what their discharge instructions actually mean, so they wind up back in the hospital. Patient didn’t pick up their prescription, so they wind up in the hospital or back in the hospital.
Patient still has uncontrolled hypertension long after being diagnosed with uncontrolled hypertension or uncontrolled diabetes. It’s crazy how many patients keep going to their doctor and being told they have high blood pressure or high blood sugar and their care plans are not adjusted. Or they don’t take their meds due to cost or a lack of trust or whatever other reason.
Or care gaps exist because the patients don’t go to their doctor in the first place. So, they settle right into a care gap that no doctor can fix because down there in the bottom of that care gap, there’s no medical professionals.
So, a year later and the year after that, their blood sugar or their blood pressure is still high. These are patients in care gaps.
I mean, consider that heart failure … I heard it called the “a little too late disease” by William Bestermann, MD, the other day. You don’t just spontaneously develop heart failure, after all. If you have uncontrolled hypertension and/or uncontrolled diabetes for too long, you will get heart failure and you’ll also probably get chronic kidney disease.
Chronic kidney disease, by the way, is often the cause of most heart failure readmissions, so think about the entire impact of heart failure and most kidney disease when you think about the cost of care gaps.
This is what we talk about today. And with that, here’s your encore.
In this healthcare podcast, I’m speaking with Carly Eckert, MD. It’s kinda funny, actually. I originally wanted to get Dr. Eckert on the show to talk about care gaps and how to close them, but this show did not wind up going how I thought it was going to go because Carly Eckert is a physician by training who got really interested in the upstream causes of what she was seeing in clinical practice. Despite my best efforts, she refused to be lured into my closing care gaps conversation. So, instead, this conversation is about the construct of care gaps and thinking about them in context. Closing care gaps is a model of care and maybe not a particularly great one, relatively speaking. In fact, here’s another name for the model of care called closing care gaps: care gap whack-a-mole. Care gap pops up … we whack it. Care gap pops up … we try to close it. Another care gap pops up … we try to close it. Another care gap … you get the idea.
Carly Eckert has worked in epidemiology and public health and also clinical informatics for health systems and payers.
I recorded this show with Dr. Eckert prior to EP359 with Dan O’Neill. In that interview, which you should go back and listen to when you have a sec, Dan O’Neill cleared up a couple of things that I struggled with during this interview.
Here’s the big one that I could not figure out: Why with the whack-a-mole? Why do we still insist as a nation on waiting for someone to show up in clinic to retroactively and reactively address a missed preventative care opportunity?
Why don’t so many more provider organizations create pop health programs that consider the whole person proactively? Why don’t they take the time to operationalize whole-person care in a meaningful way?
Ah, yes … to the surprise of exactly no one, it’s all about the Benjamins.
As Dan O’Neill put it, if all a provider organization is doing is slapping a sheet on a doc’s desk every morning with a list of care gaps for all the patients that he/she will see that day, it’s highly likely that incentives, or penalties to do anything else, are very weak. It

One of the questions I often get asked is this (actually, it’s more of a comment usually than a question): Someone says, “Seems like this whole transformative primary care thing is pretty much just, let’s go back to the old country doctor. Let’s just have a single doctor out there taking care of patients like a Norman Rockwell painting.”
To which I reply (and I’m channeling many experts, including my guest Robert Pearl, MD, when I do), “Yeah … except no.” In the golden olden days of the “ye olde country doctor,” there was a lot of art in medicine and a lot less science. If someone got cancer or even heart disease, what was required, fairly exclusively, was comfort and compassion.
Now, first and foremost so there’s no confusion, am I dismissing the importance of bedside manner and of providing comfort and compassion? Hell no. Would rather have that any day of the week than deal with a “drive-by PCP” or “drive-by specialist” with the throughput of a freeway who has no idea what I may befall the second I step out of his or her exam room.
But in the olden days, medicine was fundamentally art with a lot less science … because there wasn’t much science. For the most part, we didn’t have data. Or MRIs. This was before the whole pharma industry for the most part. We had weird heroin-infused tinctures, but we didn’t have oncology meds or biomarkers or even statins for Pete’s sake. Consider all the new diabetes meds and biologics and artificial joints and sub-subspecialists who have, through data and advanced analytics by looking at patients across the country, proven out some best practices that might be fairly unintuitive—or disproven some conventional wisdom.
It’s a different and much more complicated world today, and what’s required now is a healthy appreciation for not only the art of medicine but also the science. And science inherently means that, yeah, there are standards of care to be adhered to. That’s what science means. There are rules and better ways to do things as proven by looking at the data and not relying primarily on personal recollections of what may or may not have worked in the past. Listen to the shows with Bob Matthews (EP315) or Alex Akers (EP154) for more on this topic, but this all leads me to the interview with Dr. Robert Pearl in this healthcare podcast where we get into some concepts that he covers in his new book, Uncaring.
In this episode, we’re talking about some how-tos for being a leader of doctors, going about that against the backdrop of this evolving art and science of medicine dynamic, and the impact of this evolving art and science dynamic on physician culture and self-esteem. Because (spoiler alert) if a doc is following evidence-based guidelines, not relying solely on their own personal experience, does that make said doc feel like they are being devalued and that they are but a cog in the wheel and practicing so-called “cookie cutter” medicine? So many nuances, so little time. But, yeah, there’s a lot going on which, at its core, is this tension that can play out in some big bad ways.
I asked Dr Pearl for some advice for today’s healthcare leaders, and he did not disappoint. He suggested using a model that he calls the A to G model, and, in short, you’ve got to have:
A: an aspirational vision
B: behaviors
C: context
D: data
E: engagement (throughout the organization and also with the patient)
F: faculty
G: governance
You’ll have to listen to the episode for the why and how of each of these.
My guest today, as aforementioned, is Dr. Robert Pearl. I am sure that most of our Relentless Tribe who are listening to the show today already know Dr. Pearl, but in short, he was the CEO of Kaiser Permanente for 18 years. Now he hosts a podcast called Fixing Healthcare. He teaches at the Stanford Graduate School of Medicine and Business. He writes articles for Forbes and elsewhere. He’s also an author. He wrote a great boo

During the recording of episode 409, where Larry Bauer was explaining some really cool and innovative bright spots in the healthcare industry created by physicians, we somehow got off on a tangent about an article in JAMA from 2010—and I was all in. Unfortunately, going all in on a topic that has nothing to do with the actual topic of the currently in progress podcast means one thing; and you probably know by now what that one thing is. Yep … summer short. So, let me unveil for you our last summer short of 2023. In this healthcare podcast, we’re gonna talk about doctors and the societal perception of them as being a knight, a knave, or a pawn.
All of this is from a JAMA article that is entitled, surprisingly enough, “Societal Perceptions of Physicians: Knights, Knaves, or Pawns?” and it’s by Sachin Jain, MD, MBA, and Christine Cassel, MD, and is unfortunately firewalled (but I’ve linked to it anyway).
To get us started here, this is the first sentence of that JAMA article: “The British economist Julian Le Grand suggested that public policy is grounded in a conception of humans as ‘knights,’ ‘knaves,’ or ‘pawns.’ Human beings are motivated by virtue (knights) or rigid self-interest (knaves) or are passive victims of their circumstances (pawns).”
And, yeah, that plays out. Why can’t physicians own hospitals? Well, in somebody’s eyes, docs got a knave rap. How’d that happen? I don’t know. I can make some guesses.
Even if it’s a small percentage of docs doing knave-y money grabs or power-hungry things, there is spillover. We societal humans, after all, like black and white, not gray. So, everybody gets painted with the same brush in the same color, and policy gets created to control the lowest common denominators.
I loved this conversation with Larry Bauer that follows because it explains a lot of sequelae, if you will, that I couldn’t quite put my finger on the root cause of.
So, in the brief but fast-moving clip of the conversation that follows, Larry Bauer and I chat about docs as knaves or knights. But we don’t get around to pawns, so I did just want to chuck in my two cents here about this third category. I also will say that since I’ve got these three new classifications, I find myself using it to predict actions—to some effect, I might add.
I was chatting with someone recently, and I said something about doing well by doing good and he replied, “Well, how about this? You can do the good, and I’ll focus on doing well by doing well.” Okay … so, that’s a predictive layup.
The harder ones are where people with a lot of press training and social capital do talks about doing good and being knightly, but then you listen to the minutes of their board meetings and, wow, are they focused on revenue maximization … at the expense of patients and their fellow doctors. This happens more often than I would like to see, but then again, I would like to see this happen never.
As I mentioned about eight sentences ago, the category we don’t talk about in this conversation with Larry Bauer that follows—which has also occupied a chunk of my mind space lately—are pawns. As with all of these categories, it’s not just docs who fall into them but everybody else, too. Pawns are super interesting. You might be way ahead of me here and have been thinking about this for years because, on its face, this is obvious. But sometimes there’s truth hiding in plain sight, so I’m not embarrassed to keep talking about this in case it helps you connect the same dots I’ve recently started to connect.
I will state at the outset here that those who I would chuck in the pawn category do not listen to this podcast (neither do knaves). They do not like this show at all. This show forces a level of self-reflection and awareness and, to some degree, accountability about the net net of some of the goings-on that those who don’t want to hear it don’t like at all.
I was reading an art

On our Web site, relentlesshealthvalue.com, there is a little orange button that says send us a voice message. If you have a question, feel free to click on that button and we’ll try to round up a posse to answer your question if we can.
So, let’s do this thing.
“Hey, Stacey! Really big fan. Really loved the last episode. I had a question. Could you provide more clarity on what the key takeaway was about the actuaries and the different timelines that they’re working on versus physicians? I would greatly appreciate it. Thanks.”
Great question.
And yes, I did kind of drop in an episode something about risk horizons with no explanation. Instead of trying to answer that question myself, I reached out to a couple of actual actuaries, Keith Passwater and JR Clark. I’m gonna play their answers and give a little color commentary before and after to kind of knit together this whole thing into a few succinct takeaways for you.
Keith Passwater is former senior vice president and chief actuary over at Anthem. Keith founded Havarti Risk Services. He brings better risk products and services to healthcare clients. Keith is also a Fellow of the Society of Actuaries, a member of the American Academy of Actuaries, and he serves on the General Committee of the Actuarial Standards Board.
JR Clark is SVP of health plan product and strategy at Paytient Technologies, where he partners with thoughtful employers, insurers, and health systems to help people better access and afford healthcare. JR is known for his public exchange marketplace strategies (and that’s relevant for today) and the creation of alternative products in the individual and small group segments.
So, our panel here is strong is the bottom line. I do want to take a moment to underscore five times that if any healthcare transformation is going to happen, whomever is transforming pretty much anything must—and this is mandatory—they are going to have to be hip to hip with an actuary. But a special kind of actuary—one who applies their considerable smarts to factor in the patient or member as an actual stakeholder in their equations, because what now? Came to discover that in most actuaries’ current models, the impact on the patient or member is not part of their equation. Yeah, yes, you heard that right. Despite the fact that study after study shows that once co-pays or coinsurance reaches a certain dollar amount, patients will start abandoning care, as just one example. And despite financial toxicity being clinical toxicity, and how the cost of care can be a comorbidity, as Cody Coonradt has put it, you only have a small percentage of actuaries who are factoring this in when adding and subtracting and toting up the benefit design.
So crazy, especially because even if you forget about the human aspect here (just ignore it), I’d suspect the math is actually wrong if you ignore the patient as a stakeholder. There are financial consequences when patients abandon meds and care, and some of them manifest fairly quickly—and not in a way that is revenue positive for the plan: Diabetes patients who don’t take their insulin. Guy sees a spot on his arm. Is it melanoma? I don’t know, but I do know I’ll be $600 in the hole if I go see the doctor, so he doesn’t go until it’s really big. I mean, unless the patient dies on the quick, you’d think that there’d be some statistical contemplations about this (ie, how much does it cost plans in the short/medium term when patients who need care fail to seek it).
Actually, Alex Sommers, MD, wrote a post on this the other day. In this post about how much it actually costs when patients abandon care, he references the Four Horsemen of the Apocalypse, which is probably why I remember it.
Any actuaries out there who are taking the patient into account—or health equity is another thing—let me personally give you a round of applause. It’s really easy to feel powerless inside a big machine where everybody is

Lauren Vela is back on the pod today with a summer short that originally was a section of episode 406 that, unfortunately, I had to cut. It was a little bit tangential to the “why with the employer inertia” theme that the original episode was about. But tangential does not mean unimportant. This clip has some really critical insights on a different topic that may or may not to a greater or lesser degree contribute to inertia. And I’m gonna call this other topic the benefit design that most employees might ultimately be the most satisfied with might not be the one that they are explicitly asking for.
Let’s start with three kinds of market research insights that Lauren Vela, my guest in this healthcare podcast, uncovered when interviewing friends and neighbors not in the healthcare industry about their benefits:
1. Nobody reads their benefit information.
2. They are unhappy with their benefits.
3. The most important thing for them is to have choice. They want to avoid the notion of “managed care.”
In thinking about this, I was reminded of a Henry Ford quote: “If I asked my customers what they wanted, they would have told me a faster horse.”
Or Steve Jobs famously said, “Some people say, ‘Give the customers what they want.’ But that’s not my approach. Our job is to figure out what they’re going to want before they do.” Jobs’s whole thing, after all, was that true innovation often comes from anticipating customer needs and desires before they can articulate them themselves.
So, let me reconcile Lauren’s findings when she interviewed people about what they want in their benefits and what Henry Ford and Steve Jobs have to say about the matter.
First of all, patients/plan members—most people have never experienced a comprehensive primary care situation where they are assisted in finding the highest-quality specialists or sub-specialists and have their care coordinated. They have never had someone worrying about them in their “in-between spaces,” as Amy Scanlan, MD (EP402), put it, between appointments. This is all just a fantasy. It is a reputed Shangri-la that almost no one has ever seen with their own two eyes.
But what many have seen—I have; you have—are narrow networks in which cost containment is wielded like a brute-force weapon, where, for example, the NCI-designated cancer centers are out of network as a way to make sure that people with cancer don’t sign up for your plan … or don’t last long on your plan if they do. (Did I say that out loud?)
Do I sound like I suffer from a brutal lack of trust? Yes, I do—and I was just role-playing there an employee probably pretty accurately.
Most of us remember the HMO a-go-go years when your PCP was an administrative gatekeeper and you had to see them to get a specialist appointment—except you never could see them. Wait times were weeks or months, obviously by design, right?
But this way-too-expensive PPO model is the devil I know because, even if it totally sucks, it’s better than the conspiracy theories and/or accurate or exaggerated recollections of other options.
Here are my recommended next steps. Listen to the shows with Vivek Garg, MD, MBA (EP407), and Scott Conard, MD (EP391), and Douglas Eby, MD (EP312), as a start. All three make it really clear that advanced primary care—maybe even direct primary care—can not only save money, but it also can produce better health and patients are super happy and usually clinicians, too. It’s like a quadruple aim home run.
But none of this can happen if we say “integrated care or advanced primary care and you have to go there to get a referral” and then leave whatever that means up to employees’ or plan members’ imaginations. Communication is really required here, as it is when rolling out most new things—not just cars or cellular telephones.
 
You can learn more about Lauren’s work by connecting with her on LinkedIn.
 
Lauren Vela is a passionate a