Rethinking "No Margin, No Mission": Kenny Cole, MD

Traditional health care focuses solely on responding to clinical problems; however, patients experience the best outcomes when physicians take a holistic approach that considers multiple domains of knowledge, explained Kenny Cole, MD, MS, vice president of clinical improvement, Ochsner Health. Integrated care approaches play a pivotal role when it comes to optimizing the value and quality of care patients receive, he added.

While Cole argued the how integrated care models can help address patient barriers to the health care they need, he also acknowledged how current models—including fee-for-service—hinder this work. In this interview with The American Journal of Managed Care^®, Cole discussed these elements in more detail to demonstrate how clinical collaboration and rethinking the transactional nature of health care can help patients achieve their health goals.

These topics, patient-centered perspectives, and more, were discussed at a recent Institute for Value-Based Medicine event held in New Orleans, Louisiana, on April 10, 2025.

This transcript has been lightly edited; captions were auto-generated.

Transcript

How can integrated care models be leveraged to address health disparities and ensure more equitable access to high-quality care?

The entire historical construct of medicine has been really based on the premise that health care delivery is the exclusive domain of the physician, where the physician's job is to solve a clinical problem, to get a history, perform a physical exam, order appropriate diagnostic testing, in order to arrive at a diagnostic conclusion and then follow a treatment plan. What that premise ignores is that there are lots of barriers that can stand in the way of successful execution of a treatment plan that had nothing to do with the domain of clinical knowledge.

That's where you need alternate domains of knowledge, whether that's behavioral health or case management, a social worker, nursing, advanced practice providers, whoever that may be, that you need to consolidate in such a way as to solve the problems that arise in the journey of trying to achieve the best outcome. Some of those problems may be clinical in nature, but others are psychosocial in nature, and they're every bit as important because they can impede progress towards the ultimate desired goal of the best outcome.

In your experience, what are some of the pertinent barriers to implementing integrated care teams, and what advice do you have for overcoming them?

The biggest barrier historically has been the nature of health care financing, which typically constructs health care delivery as a series of transactions. Whenever you're using a construct of transaction-based financing, everything is built around the idea of either an office visit or encounter. Then the delivery model revolves around the revenue generation that comes from the transaction-based financing model—not because people are trying to be overly greedy. There’s the saying that you've heard around hospitals, “No margin, no mission.” The only way to build the infrastructure to be able to provide the care is to be able to get reimbursement for the services rendered.

The problem is that when all you're doing is reimbursing visits, or procedures, or imaging, then everything extraneous to the financing model becomes a cost. Then what happens is a social worker, even though they're invaluable in terms of the coproduction of a desired health outcome, they’re a cost to the system for which no reimbursement is typically given. Now, the way to try to overcome that is to reinvent the business model in such a way that you're actually trying to take accountability for the total cost of care. Because now, if you have a business model where you, the provider, are entirely responsible for the total cost of care, then ultimately what you're trying to do is to create a delivery model that decreases the total cost of care. You begin to leverage other team members in an attempt to try to accomplish that.