• A Prescription for Primary Care

    Nov 04, 2014

    Convinced that the primary care crisis is too big to be fixed by incremental changes, this physician entrepreneur decided to start from scratch.


    As a primary care internist, Rushika Fernandopulle, MD, was trained to heal patients. But in recent years, he has turned his attention to healing the broken health system, rolling out a unique approach to primary care.

    “A lot of people are trying to fix health care with small, incremental changes. We’ve been bold enough to start from scratch and try a very different approach. As a result, we are making a huge impact.”

    Fernandopulle’s fix: Building care teams around health coaches instead of physicians; eliminating patient copayments, which he believes discourage patients from using primary care services; focusing on those high-risk patients who do not typically show up at the physician’s office; and investing more money in primary care.

    “It’s ridiculous that we only spend 4 percent of U.S. healthcare dollars on primary care, and 96 percent on what we should call the ‘failure of primary care,’” he says. “Instead, let’s convince payers to pay a flat fee for primary care, and let’s double down (8 to 10 percent) on the proportion of healthcare dollars spent on primary care.”

    Listen to a related audio interview with Rushika Fernandopulle, MD, to learn more details about how Iora Health is reinventing primary care.

    What Does Different Look Like?

    To get to this vision, Fernandopulle cofounded Iora Health, which operates six primary care clinics around the country and will soon open six more. The company’s goal: 100 clinics within five years.

    Each patient is served by a team that includes an Iora Health-employed doctor and nurse, as well as a health coach who, by design, is not a highly trained healthcare professional. “The coaches are folks who are from the community, who speak the language of the people they serve, and who are picked for one reason only—their empathy—because we can teach everything else,” Fernandopulle says.

    “The coach’s job is to help patients with all the blocking and tackling needed to improve their health. That means making a plan, asking questions, and understanding the plan. It involves holding a patient’s hand when that’s the right thing to do, kicking them in the behind when that’s the right thing to do, helping them to navigate the system, and whatever else is necessary.”

    An Iora Health practice typically has eight to 10 health coaches working with two or three physicians—about four coaches per physician. Each health coach is responsible for between 150 and 400 patients, depending on the complexity of the caseload. Other clinic staff include the nurse innovators who run the practice and a social worker or behavioral health specialist.

    The practice’s electronic health record is designed to help health coaches easily identify patients who are due for preventive care services or need to have chronic illnesses monitored. “The coaches spend half their time reaching out proactively to patients,” he says. “We have a very elaborate ‘worry’ score, which tells us which people we ought to be worried about today and what we ought to be doing to try to impact their health.”

    What Are the Results?

    Iora Health’s clients include self-insured employers like New Hampshire’s Dartmouth College, union trusts that provide health coverage, and a health plan that provides insurance to freelance workers. All pay roughly twice as much for primary care services—on a capitated basis—than is typical.

    In return, Iora Health clients typically see hospital admissions for their populations decline by 40 percent and emergency visits by 50 percent, compared to the previous year. Total healthcare spending decreases 12 percent to 15 percent when the additional primary care costs are considered.

    The most important feature of each clinic is its ability to focus on the specific needs of the local patient population. For instance, in Boston, a clinic that serves members of a carpenters union, offers “Hammer Time” educational sessions to train members on how to stretch muscles and use tools in a way that will help avoid injuries.

    “While we ensure all the right things are done at every clinic, we are also good at determining what needs to be handled differently at a specific clinic because of the different population, issues, and care setting,” he says.

    Rushika Fernandopulle, MD, is cofounder and CEO, Iora Health, Cambridge, Mass.

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