The math doesn’t always add up in primary care. I know firsthand that the number of hours in a day simply can’t keep pace with the needs of today’s patients or the growing complexity of chronic condition management.

If you’re a healthcare system or health plan executive, you already know the stakes. Cardiometabolic conditions account for a staggering 86% of healthcare spending. At the same time, primary care doctors face nearly impossible workloads, needing 26.7 hours a day to meet the evidence-based needs of their patient panels.

How do you bridge the gap? You bring in a smart, scalable solution built for today’s challenges. At Ochsner Digital Medicine, our model does just that.

I was recently invited, along with my colleague Dan Shields, CEO of Digital Medicine, to present at the HIMSS Global Health Conference & Exhibition.  As Ochsner Health is a previous HIMSS Davies Award of Excellence winner, we were honored to lead a session to explain how Ochsner’s Digital Medicine solution has created a model that blends human expertise with technology proven to lower the total cost of care, help providers save time, and dramatically improve patient outcomes. This is what I shared with the audience:

‍Bridging the Gaps

Evidence shows that better cardiometabolic condition management leads to better health outcomes. Take hypertension, for example. We know that lowering systolic blood pressure significantly reduces the incidence of stroke. So the possibilities are remarkable, but time and access limit the traditional method of treating these conditions. Current standards of care rely on patients visiting the office just a couple of times a year. For something as critical as blood pressure or diabetes control, that’s simply not enough.

We are redefining what’s possible. Instead of two blood pressure readings or two A1C measures per year, we gather over 100 blood pressure readings and more than 150 blood sugar readings annually through remote monitoring devices. This constant flow of data allows our dedicated digital care teams to spot trends, act early, and ensure patients receive the right care at the right time.

And it works. Among our members with Type 2 diabetes, uncontrolled patients (A1c >8%) enter the program with a median A1C of 9.1% — which drops to 7.3%at 180 days. This isn’t just a clinical victory; it directly translates to reduced hospital visits and fewer complications, which means lower costs for health plans and systems.

‍Reducing Clinical Variability

Ask any physician, and they’ll tell you that keeping up with the latest medical research is daunting. It’s hard to believe, but medical knowledge now doubles every 73 days. For a primary care doctor managing thousands of patients, it’s nearly impossible to keep pace. And this is how clinically unwarranted care variability creeps into the system. Outcomes often depend less on evidence-based guidelines and more on which physician a patient sees, due to how the physician’s practice patterns have evolved.

Digital Medicine tackles this challenge by replacing variability with consistency. We rely on evidence-based pathways and algorithms applying the latest clinical guidelines to manage cardiometabolic conditions. And when you reduce variability and consistently apply best practices, your outcomes soar.

That’s the power of reliable, rigorous care pathways — not just for better patient outcomes but also for reducing emergency room visits, hospital stays and the total cost of care.

Real Savings, Real Value

One of the most compelling aspects of our program is the return on investment. Across our member population, we see a 38% decrease in ER visits and a 27% reduction in hospitalization rates. For health plans, these better outcomes translate into savings of approximately $2,200 per enrolled member per year.

With a per-member, per-month fee model, this yields a greater than 3-to-1 return on investment. And for the members themselves? Satisfaction is through the roof. Our Net Promoter Score hovers in the 80s, a world-class rating. Fewer than 2% of patients leave the program because they see meaningful benefits. They feel better, have more energy and enjoy improved quality of life.

A Continuous Connection

Traditional visit-based care asks patients to come to us — but that approach creates gaps. By fostering a continuous, connected relationship instead, we gain deeper insights and provide proactive care.

We’ve also found that digital solutions work for populations often considered less tech-savvy. Even among older adults (60+) or those of lower socioeconomic status, patients achieve strong engagement with the right coaching and support.

Going Beyond Cost Savings

Health systems running on fee-for-service models might view programs like Digital Medicine as a departure from their usual operations. But even here, Ochsner Digital Medicine carries distinct advantages.

For organizations with overwhelmed specialists and lengthy appointment backlogs, we can help free up access by managing certain conditions entirely within remote care teams. For example, a patient with chronic kidney disease in stage 3 might no longer need a nephrologist right away. Instead, we manage their blood pressure, monitor urine protein levels and ensure they’re on the appropriate medication.

Time Saved, Lives Changed

Ochsner Digital Medicine isn’t about replacing the physician-patient relationship. It’s about making clinicians’ lives easier, transforming care delivery and improving health outcomes. By addressing the core challenges of time, data, and access, we’ve reimagined what’s possible in chronic condition management.

For health plans and healthcare systems looking to save money while empowering providers, this is the model they want. It’s time we move beyond episodic care to build connected relationships that improve life for everyone involved.

We believe this is how cardiometabolic conditions should be treated, and we do this because it’s the right thing to do. Is your organization ready to take the next step? Contact us.

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