Clinical Consulting – Converging Health

Relentless Health Value: Episode 462 with Converging Health’s…

Today, Dr. Scott Conard discusses the evolution of his life’s work, focusing on his current collaboration with Mike Adams from 7-Eleven to support their plan members. Their efforts revolve around a few striking yet common insights that many plan sponsors will recognize in their own data. One key finding: roughly 70% of individuals who exceed a plan’s high-cost threshold in any given year were previously high-risk but low-cost. These individuals don’t appear out of nowhere—they were identifiable in prior years. The challenge is to identify them early and provide the right interventions to prevent them from transitioning into the high-risk, high-cost category. Effectively managing a population requires proactive identification of high-risk, low-cost members before they escalate into high-cost care. To achieve this, Dr. Conard follows a best-practice, stepwise approach, which we’ll outline below. While we cover each step in the discussion, some are explored in greater depth than others. Best-Practice Approach to Managing Population Health 1. Get the Data – The Whole-Person Risk Score Rather than categorizing members into isolated disease groups, the goal is to assess risk at a whole-person level. Patients aren’t just a collection of separate conditions—they’re complex human beings whose health factors interact. Dr. Conard often uses a car analogy: If a car’s tires wear out, you simply replace them. But humans don’t work that way. A patient may need surgery but be unable to proceed because their cardiovascular markers are too high. Yet, they can’t take the necessary medication due to contraindications with existing kidney or liver conditions. This fragmentation in care often leads to patients being bounced between specialists who don’t communicate effectively. A real-world example comes from Miriam Paramore, who shares a harrowing story about her father’s end-of-life care—an illustration of why whole-person risk scoring is critical. 2. Provide Access to Advanced Primary Care Teams Members need access to high-functioning primary care teams that are empowered to make informed referrals to top-tier specialists. These teams should ensure care is high-quality, appropriate, and optimized for each patient. 3. Align Benefit Design with Optimal Care Pathways Plan sponsors must structure benefits to support the care members need. If benefit design creates barriers—like high co-pays for essential services—members may forgo necessary care, leading to worse outcomes and higher costs in the long run. Dr. Mark Fendrick once compared benefit design and optimized medical care to peanut butter and jelly—they must go together. For example, if a doctor tells a diabetic patient to get regular foot exams to prevent amputations, but the patient can’t afford the co-pay, the system fails. The patient suffers, the doctor’s quality scores take a hit, and the plan sponsor ultimately pays for costly, avoidable complications. Step 3 ensures benefit design supports, rather than hinders, effective care. 4. Engage Members with Navigation Tools Members need guidance to navigate the healthcare system effectively. Tools like My Personal Health Assistant play a crucial role in engaging unengaged patients and ensuring they follow optimal care pathways. These tools complement advanced primary care efforts, helping members stay on track and receive the right care at the right time. By following this structured approach, plan sponsors can proactively manage population health, reduce costs, and improve outcomes—transforming their approach from reactive to strategic.

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Primary Care for All

1 Comment / Clinical Consulting / Converging Health Website

An initiative that will transform the U.S. health system so that it is driven by Advanced Primary Care by Scott Conard, MD There is a group of us who are working together to bring a foundation of advanced primary care to every American. With this foundation we can establish a “system” of care for America that will significantly reduce the confusion, disorganization, low health literacy, inappropriate navigation, and excess costs. At this time our initiatives are:To Renew the commitment to a primary care system: Create a renewal process that will stimulate deep reflection that leads to re-discovery and embrace of the core values, goals and sense of purpose that underlies the Family Medicine movement To Revitalize those believing in the value of advanced primary care: To inspire and to articulate a vision for the next stage that engages a community of innovators and early adopters who will act on the vision. To Transform the system: To advocate and act on systems change: from models to networks to systems to institutions. All of this is based upon primary care that makes a difference. Running patients through 40/day, handing out referrals and scripts at a record rate, at 7 minutes a visit or spending an hour with every patient, ordering every possible test – regardless of evidence base and/or pre-test probability. Nor is it about ignoring what is going out outside of the office and just caring for those who call and make an appointment. Advanced primary care calls us to provide a higher level of service and care. Truly in the old “Marcus Welby” vision of caring for people as they age – having a trusted relationship – and ensuring patients get the right care, at the right time, in the right place, and at the right cost. What are your thoughts about this? Is it realistic? Is it fair to ask primary care providers to do more without providing better tools, better data and information, proactive reimbursement, or other support?

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We Are Healers

Clinical Consulting / Converging Health Website

We did not go into medicine to survive in a system of computer/paper work, administrative hassle, financial struggles, or corporate employee gamesmanship. by Scott Conard M.D. We are healers, and we make a tremendous difference in our patients lives. But misaligned incentives, the industrialization of medicine, legal and administrative burdens, and the perceived lack of value of primary care is creating a situation where surviving has replaced thriving. Our patients, the corporations they work for, and the US need us to get back to our purpose. The healthcare system must be built on a foundation of high quality, advanced primary care – and those delivering it must thrive, not just survive. This transformation begins with primary care providers investing in themselves and becoming the influential forces they can be. Working together, standing for themselves and their patients, with a clear and articulate message, we will make a stand for our value, the health and well being of our patients, and the success of our practices. If you are in primary care and are ready for change, then come reconnect with why you went into medicine, reconnect with the excitement and satisfaction you imagined, and become the leader in your lives, practices, community, and maybe the nation for the primary care system that will serve you, your patients, our corporations, and the country. Read more: https://themdceo.com/we-are-healers/

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Revolutionizing Population Health Risk Reduction: A Shift from Historical Costs to Root Causes

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

Written by Scott Conard, MD When it comes to population health risk reduction, the conversation is evolving. Historically, in the U.S., managing health costs has often been approached from an actuarial perspective—calculating insurance premiums based on past expenses and statistical projections. While this method has served its purpose, it focuses on trailing indicators like price per procedure and frequency of use, leaving the underlying drivers of healthcare costs largely unaddressed. But now, a shift is happening. We’re moving beyond simply accounting for costs to asking critical questions: What’s causing these costs to rise? What are the leading indicators that drive health risks and, ultimately, healthcare utilization? Moving Beyond Actuarial Science Traditional actuarial science calculates costs by factoring in variables like age, geographic location, medical diagnoses, and prescription usage. Insurers then project future costs based on past patterns, layering in adjustments for population demographics. While precise in its methodology, this approach is inherently backward-looking, focusing on how much was spent last year rather than proactively addressing what might reduce future spending. At its core, healthcare costs boil down to two key factors: price and use. But focusing solely on these metrics ignores a fundamental truth: the largest driver of healthcare cost is the risk of illness within a population. A high-risk population will inevitably lead to higher utilization and costs, while a low-risk population is significantly less expensive over time. Identifying and Addressing Health Risks To reduce health risks, we must first identify them. The answer lies in analyzing the population’s disease burden and the lifestyle factors driving it. Experience has shown that approximately 30% of a company’s population will eventually account for the majority of high-cost claims. More importantly, about 70% of those costly claims stem from conditions that could have been mitigated through early intervention and risk reduction. Lifestyle and Emotional Health: The First Line of DefenseMany of the conditions driving healthcare costs are preventable. Addressing lifestyle factors and emotional well-being plays a pivotal role in risk reduction. Strategies include: Navigating Healthcare Smarter The second pillar of health risk reduction involves empowering individuals to make smarter healthcare choices. This includes: High-Quality Care = Lower Costs A critical insight emerges when we focus on proactive health management: the highest-quality care is often the least expensive care. By identifying and addressing risks early, we not only improve health outcomes but also manage costs more effectively. Predictive analytics allow us to foresee who may require expensive treatments like surgery or dialysis, enabling timely interventions that are both effective and cost-efficient. The Future of Population Health This shift in focus—from trailing indicators like price and use to leading indicators like disease risk—represents a fundamental transformation in how we approach population health. By addressing the root causes of illness, promoting healthier lifestyles, and ensuring access to high-quality care, we can achieve significant reductions in healthcare costs while enhancing overall well-being. The path forward is clear: organizations must prioritize proactive health management strategies that address the underlying drivers of risk. By doing so, they can create healthier populations, reduce costs, and foster a more sustainable healthcare system. This isn’t just good for business—it’s essential for the future of healthcare. Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

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The Real Enemy in Healthcare Benefits: Fighting Disease, Not Just Managing Costs

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

By Mike Adams and Scott Conard MD When it comes to healthcare benefits planning, companies often get sidetracked, thinking that the main challenge is controlling costs. But here’s the real truth: the true enemy isn’t high premiums or rising deductibles; it’s the disease itself. Disease is what drives up healthcare costs, disrupts productivity, and takes a toll on both employees and employers. By refocusing our efforts on fighting disease and supporting long-term wellness, we can create a sustainable, effective healthcare benefits strategy that benefits everyone. Empowering Employees to Fight Disease: A Partnership Approach In the fight against disease, employees and employers need to align their efforts. Employers play a crucial role in providing the resources, financial assistance, and tools employees need to manage their health effectively. But it’s not just about giving access to healthcare services; it’s about fostering a proactive health mindset. Employees need to take ownership of their health. This partnership means that while companies provide the tools, employees must also put in the effort to use them effectively. Moving from Transactional to Relational Healthcare One of the biggest obstacles to creating a sustainable healthcare strategy is that too many people still view healthcare as purely transactional. In the traditional model, employees go to the doctor when they’re sick, get a prescription, and call it a day. However, this approach doesn’t solve the root problem; it merely addresses symptoms as they arise. The solution is a shift from transactional to relational healthcare. Just as financial advisors moved from selling stocks and bonds to holistic wealth management, healthcare providers are starting to focus on population health management. This approach prioritizes long-term health and wellness over short-term treatment and one-off doctor visits. Population health management looks at the bigger picture—helping individuals stay healthy and preventing disease from occurring in the first place. The Problem with Cost-Centered Benefits Planning Many companies have relied on brokers, insurance providers, and pharmacy benefit managers (PBMs) to reduce costs. However, focusing only on cutting costs without addressing the underlying issues—namely, disease and lack of preventive care—leads to a broken system. Often, these brokers and PBMs are incentivized by rebates, prescription volume, and other revenue-driven structures. This creates a conflict of interest, where decisions may prioritize profit over the well-being of employees. Year after year, this results in a steady increase in healthcare costs, with the average annual rise in premiums hovering around 5% to 10%. To break this cycle, companies must shift their focus from short-term savings to addressing the real issue: preventing and managing disease. Only by aligning incentives toward long-term health outcomes can companies sustainably control healthcare costs. Disease is the Enemy: The Path to Sustainable Healthcare Benefits The true solution lies in approaching disease as the primary challenge. When employers focus on health improvement instead of just managing expenses, they can create a benefits plan that is both cost-effective and impactful. This involves: When employers and employees work together, supported by a healthcare benefits plan that prioritizes fighting disease, the benefits extend beyond the bottom line. Healthier employees lead to a more productive, engaged workforce, reduced absenteeism, and ultimately, lower healthcare costs. Building a Healthier Future: Fighting Disease Together By recognizing disease as the real enemy, companies can begin to reshape their healthcare benefits strategy in a way that truly serves employees’ needs. Empowering employees to take charge of their health, focusing on preventive care, and partnering with providers who share a commitment to wellness can transform healthcare from a transactional system to a relational, proactive one. Disease is the real enemy in healthcare benefits planning, and by uniting against it, we can create a system that doesn’t just manage costs—it improves lives. Let’s move past broken incentives and focus on what truly matters: building a healthier, more resilient workforce.

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Health Risk Engagement Strategies: Driving Change Before It’s Too Late

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

For executives managing health plans, one of the biggest challenges is engaging individuals who are in the early stages of disease risk progression but feel perfectly fine. These individuals, often unaware of the looming consequences, present a significant opportunity—and a unique challenge—to healthcare strategies. Once someone becomes symptomatic, behavior change is much easier; they’re desperate to feel better. However, by then, it’s often too late to reverse the damage. Instead of cheaply and effectively addressing the issue, we’re left managing a chronic condition for the foreseeable future. The key question: How do we engage people early, before symptoms appear, and inspire them to take meaningful action? This is where cutting-edge health risk engagement strategies, driven by predictive data and real-time activation technology, become a game-changer. Our algorithms utilized by the MyPHA team is your solution to this problem. Shifting the Paradigm: From Retrospective Cost Analysis to Proactive Risk Engagement The status quo in healthcare analytics relies on retrospective cost-based reporting. Most organizations are equipped with tools that answer questions like: These data points are useful for understanding the past but do little to impact the future. They focus on individuals who are already in the high-cost, high-risk category—individuals whose health trajectory has already caused irreparable harm. What’s missing from this equation is predictive engagement—the ability to identify the individuals who are trending toward risk before they become symptomatic and to intervene effectively in real time. Consider this: 70% of today’s high-cost individuals won’t be the same people next year. If you’re only looking at historical data, you’re blind to the emerging risks within your population. Why Predictive Engagement Matters Let’s look at the CFO perspective:“I’ve already got reports. I know I have 384 diabetics and 264 people with hypertension. I have programs in place for them. Why do I need anything more?” Here’s why: Traditional reports don’t tell you who your next high-cost individuals will be, nor do they provide actionable insights about how to prevent them from becoming costly. They miss the nuances of health risk drivers—factors like comorbidities, social determinants of health, geographic influences, and behavioral patterns—that determine whether an individual can avoid a serious medical event. Predictive engagement goes beyond labels and costs. It examines the whole person—integrating data about: This holistic approach enables organizations to answer the most critical question: How can we prevent costly and emotionally taxing events before they occur? Engagement, Activation, and Support: The Pillars of Early Intervention Effective early intervention requires a three-pronged approach: For employers, early intervention is not just a health imperative; it’s a financial one. But this requires a shift from reacting to past costs to proactively managing future risks. By investing in predictive analytics and engagement technology, organizations can reduce costs while improving outcomes for individuals. Conclusion: The Future of Health Risk Management The old approach—focusing on retrospective cost and disease management—is no longer enough. Health risk engagement strategies must evolve to focus on real-time insights, whole-person care, and proactive prevention. The stakes are high, both for individual lives and corporate budgets. But with the right strategies, tools, and commitment, we can make a measurable difference—shifting the focus from managing disease to building health and resilience. As executives, the question isn’t, “Why should I care about your data?” It’s, “How can I afford not to?” By embracing proactive engagement, activation, and support, you can ensure your organization is leading the way in creating healthier, more productive populations. That’s a future worth investing in.

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Realigning Incentives for Better Health Outcomes and Lower Costs

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

For executives responsible for managing their organization’s health plan, there’s a crucial question worth asking: Is our current system really designed to treat each individual and improve their health? On the surface, the answer might appear to be “yes.” After all, the system has data, information, resources, and influence at its disposal. But take a step back and ask yourself: How is it working for you? If the system truly prioritized individual health, the numbers would tell a different story. Healthcare costs in the U.S. would be at least half of what they are today. Instead, costs continue to rise at a staggering rate of 5% to 10% annually, leaving organizations and their employees struggling under the weight of increasing premiums, higher deductibles, and diminished outcomes. The Misaligned Incentives Here’s the hard truth: The current system is not designed to treat the individual effectively. Why? Because misaligned incentives drive it. Many players in the healthcare ecosystem profit more when costs go up. In fact, rising costs are often baked into their business models. This misalignment has created a scenario where nearly one-third of healthcare spending is wasted on fraud, waste, and abuse. These inefficiencies enrich middlemen and other unnecessary stakeholders while leaving employers and employees to foot the bill. Worse yet, 70% of high healthcare costs could have been prevented if root causes were addressed earlier. A Smarter, More Aligned Approach What if we could use the same intelligence—data, information, and systems—but act on it differently? What if we focused on making people healthier and tackling waste at its core? This approach is not only possible but also financially and operationally realistic. By investing in high-quality care that addresses the root causes of health issues, organizations can achieve better outcomes and lower costs. High-quality care is the least expensive care because it prevents the need for costly interventions and reduces the churn of treating symptoms without resolving the underlying problems. A Path to Sustainable Savings Consider this: if we worked to eliminate a portion of fraud, waste, and abuse each year for the next five years while improving the health of employees, could we stabilize our costs? The answer is a resounding “yes.” Here’s what that path looks like: The Payoff By realigning incentives and focusing on root causes, companies can break the cycle of escalating costs. Over time, this shift leads to a healthier workforce, more predictable expenses, and a competitive edge in attracting and retaining talent. As leaders, it’s up to us to ask the tough questions and take bold action. The fly in the sauce isn’t going to fix itself—but we can. Together, we can create a system that works for individuals, organizations, and the bottom line. Are you ready to take the first step toward a healthier future for your team and your company?

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