I was recently invited by Dr. Marc-David Munk, the Vice President, Accountable Care and Senior Medical Director for Medicare Practices at Iora Health to visit the “nest”, the home office of Iora Health. [Iora is a species of beautiful little birds found in India and Southeast Asia, as shown in the picture.] Iora’s home is in the heart of Boston on the “Freedom Trail”.The plan was that he would show me around their office and then we could be joined for a conversation over lunch with Dr. Rushika Fernandopulle, who cofounded Iora with entrepreneur Christopher McKown, the husband of Abigail Johnson, chief executive of Fidelity Investments.
I have been very interested in Dr. Fernandopulle’s work since I read Atul Gawande’s fabulous New Yorker article, “The Hot Spotters”, back in 2011. The article was an exciting read for anyone who was convinced that it was possible to lower the total cost of care while improving quality. Dr. Fernandopulle’s innovative practice was one of several examples presented but it was the one that most interested me because it seemed to resonate with Dr. Ebert’s wisdom. The article presented a pretty complete picture of the salient features of the Iora Health approach to lowering the total cost of care for casino and hospital workers in Atlantic City.
Below I have lifted key points from the article:
- [the] experiment started in 2007 by the health-benefit programs of the casino workers’ union and of a hospital, AtlantiCare Medical Center, the city’s two largest pools of employees. Both are self-insured—they are large enough to pay for their workers’ health care directly—and both have been hammered by the exploding costs.
- Fernandopulle [who trained at the MGH in primary care and opened his first practice in Arlington] created a point system to identify employees likely to have high recurrent costs, and they were offered the chance to join the new clinic.
- The union’s and the hospital’s health funds agreed to switch from paying the doctors for every individual office visit and treatment to paying a flat monthly fee for each patient. That cut the huge expense that most clinics incur from billing paperwork… The payment scheme…allowed him to design the clinic around the things that sick, expensive patients most need and value, rather than the ones that pay the best.
- He adopted an open-access scheduling system to guarantee same-day appointments for the acutely ill.
- He customized an electronic information system that tracks whether patients are meeting their goals.
- …he staffed the clinic with people who would help them do it. One nurse practitioner, for instance, was responsible for trying to get every smoker to quit.
- As in many primary-care offices, the staff had two physicians and two nurse practitioners. But a full-time social worker and the front-desk receptionist joined in for the patient review, too. And, outnumbering them all, there were eight full-time “health coaches.”… Each health coach works with patients—in person, by phone, by e-mail—to help them manage their health.
- The coaches work with the doctors but see their patients far more frequently than the doctors do, at least once every two weeks. Their most important attribute, Fernandopulle explained, is a knack for connecting with sick people, and understanding their difficulties. Most of the coaches come from their patients’ communities and speak their languages…“We recruit for attitude and train for skill,” … “We don’t recruit from health care…”
ER visits were reduced more than 40%. Patients were better; remarkable improvements occurred in the control of blood pressure and cholesterol. Sixty-three per cent of smokers with heart and lung disease had quit smoking. In a study comparing the patents in the practice to matched controls of workers in Las Vegas, the Atlantic City workers experienced a twenty-five-per-cent drop in costs while experiencing improved outcomes.
This success did not go unnoticed or unresisted. Some doctors in specialties in both the ambulatory and hospital environment to whom the patients needed referrals weren’t about to let that business slip away. Gawande’s comment was:
As the saying goes, one man’s cost is another man’s income.
The hospital system was in a difficult position but the CEO recognized that the greatest potential harm to the community was the rising cost of care. As Gawande noted:
The Atlantic City economy, he [the hospital CEO] said, could not sustain his health system’s perpetually rising costs. His hospital either fought the pressure to control costs and went down with the local economy or learned how to benefit from cost control.
Since 2011 Iora has grown. That growth is based on the further evolution of the model of care as described on their website and the continued use of culturally competent health coaches and the full integration of behavioral health into primary care. It now has practices in New England, the mid Atlantic, Midwest, Colorado, Arizona and Washington State. It plans to open in Atlanta and other sites in the midwest soon. There is a blueprint that is being consistently applied that includes the elements that Dr. Gawande found and described at the site in Atlantic City, but every practice is also unique.
Fee for service finance is one of the greatest barriers to clinical innovation. By finding clinical partners who bear risk and have much to gain from more efficient and effective practice and are willing to “prepay” for care, Dr. Fernandopulle has cleared that huge barrier. In a very informative set of interviews published by the Harvard University Center For Primary Care he addresses the issues of finance, including the support of venture capital, and the for profit status of Iora.
The first interview explores the history of Iora and Dr. Fernandopulle’s personal history and philosophy. Iora stands as evidence that innovations in primary care quality can contribute to the Triple Aim by lowering cost while improving quality and satisfaction for difficult populations. The second interview focuses on the future challenges of Iora and all of primary care.
Here are a few excerpts from the two interviews:
- I remember one day, during my primary care residency at Mass General, I had spent a typical afternoon seeing patients and then stayed late to fill out their electronic health records. I was chatting with a colleague, and she said, “Every day I lose a little piece of my soul.” My response was, “You’re right!” We went into this to help people. People come to us with such big needs, but I have only 7 minutes and I have to do all this other junk and I don’t have the support I need. I didn’t know if I could keep doing it this way for 30 more years. The simple realization was that we created this stupid system and so we should be able to fix it…
- One thing we think a lot about is that we see the organization as a flipped pyramid. It’s not the CEO on top and then the division chiefs— the patients are in charge…We then have health coaches who are from the community— they work for the patients, and they’re the closest to them. The doctors support the health coaches, and the job of the “Nest” (Iora’s a bird, so the central office is called a “Nest”) is to support everyone above us….People closest to the care come up with all the good ideas, not us. We just need to allow it to happen.
- One question I often get is, “Why are you a for-profit company and not a non-profit?” I think we have to get over the idea that “non-profit equals good, for profit equals evil.” One’s tax status has nothing to do with how mission-driven or effective they are. ….Transforming healthcare is a huge problem. If we want to do it right, we need real capital…
- Primary care is actually very different depending on the population you serve—building the right primary care for seniors is different than building it for young healthy people, or for people at the end of life. …Each practice is targeted to specific populations. By doing this, we’re trying to learn, “how do you optimize primary care for this population?”
- …at our team meetings, we talk about our “spectacular failures”, and we celebrate them. …The key is, “…and this is what we learned from it.” It will be a failure if you don’t get that last part of the sentence: what we learned from it.
A good article from the Boston Globe last year gave me an updated view of Iora but I was not prepared for “the nest”. There were dozens of “twenty and early thirty something” young people with MacBooks working on long tables and in small groups. There were only a couple of conference rooms but even those had glass walls and I imagined that whatever was being discussed was open for the input of anyone. I was told that one group was modifying the home grown electronic medical record to be a better tool for population health. One major advantage that Iora has is that there is no billing function to its EMR. It is all clinical. The EMR is designed and modified by the Iora clinicians to support their team based care and it is an open door for patient communication.
In my conversations with Dr. Munk and Dr. Fernandopulle it was obvious that there are challenges to their future. One is the relationship with specialty practices and hospitals. Another is how to grow. Currently they are dependent on relationships with partners who have something to gain by reducing the utilization of specialty services, hospitals and emergency services. The model has intensive professional needs. The redesigned role of physicians at Iora may create a future problem for growth.
I plan to visit the Dartmouth practice of Iora and compare what is happening there with Dr. Ebert’s experiment in 1969, the creation of Harvard Community Health Plan. HCHP and Iora both began as greenfield projects. Healthcare reform and the movement from volume to value are really brownfield projects and suffer from a sense of loss. “Adaptive change” is the predominant issue in the brownfield world and that is a drag on innovation. In the greenfield world the energy is creative and there is a pioneer spirit.
In an established system of care, today’s work work makes innovation almost impossible. Conversely, in the innovator’s world, integrating what is new with what exists inevitably produces conflicts. Iora’s success comes at the expense of the status quo. Innovation is part of a process called “creative destruction”. Iora is “intuitively Lean”. The daily huddle and the upside down nature of the practice are Lean objectives that often take several years to master. Will Iora be able to continue its unique culture and operating system as it grows with the help of its finance partners? I truly hope that it will.
Years ago I imagined HCHP as an “island” with its own economy and populated by “pioneers”. One day we faced the reality that we had to be integrated with the wider world. If we were going to survive, we needed to grow. To grow we needed to attract professionals and most were not “pioneers”. They wanted “a market compensation for market responsibilities”. It was as if we had built a causeway from our happy little island to the realities of the “mainland”. I sense that Iora is fast approaching some of the same realities that faced HCHP.
I know one thing for sure about Iora, there is an infectious spirit of “can do” that embraces you the moment you walk through the door. It is a reality that we cannot turn all of American medicine into a greenfield start up but I do believe that finding ways to integrate what pioneer innovators like Iora are learning into our failing brownfield practices would be an endeavor that offers all of us a path to
Care better than we have ever seen, health better than we have ever known, cost we can all afford, …for every person, every time.
