American health care may be a mess, but many founders clamor to fix it. Among them: physician Rushika Fernandopulle, whose Boston-based company, Iora, reworks the primary care experience. Iora charges each patient a monthly flat fee--about $150, often covered by insurance--instead of using today's baffling and complex system of copays and billing codes. Iora also pairs each patient with a health coach to ensure that he or she follows doctor's orders. This model, while more expensive up front, addresses problems early on to save consumers and insurers money in the long run, by cutting down on emergency-room visits and long-term care for chronic conditions. Fernandopulle launched Iora in 2012, with one clinic in New Hampshire and another in Nevada. To date, Iora has raised more than $42 million and opened 11 more clinics. And Fernandopulle is planning for 30 locations by 2016.
--As told to Liz Welch
Stupid Systems and the Soul
It was 2002 and I was working as a primary care physician in Boston. I'd seen 40 patients, and had to stay two hours after work to finish up my notes, because that's what these stupid systems make you do. My colleague was doing the same and said, "We went into this to help people. Every day, I'm losing a little piece of my soul."
Our health care system is based on billing and coding and checking boxes and rules. That doesn't heal people. Relationships do. I decided to build a new model from scratch and change everything. A lot of people are trying to fix health care from the top down. We decided to start from the bottom--with primary care, where the real relationships begin.
The Power of Coaching
If I say, "Eat a low-carb diet," and my patient doesn't understand what that means, how can she improve her health? Each of Iora's patients has a dedicated health coach who discusses the individual's issues before the doctor arrives. The coach then stays during and after the exam to translate the doctor's recommendations into an actionable plan.
The most important skill for this job is empathy. We have intensive four-week training, during which we teach our coaches how to do things like take blood pressure and measure blood sugar, as well as motivational interviewing so they can figure out what the real problems are. We look for thoughtful people within the community being served, because they understand the culture. We barely look at résumés--instead, we have applicants do speed dating with our other health coaches. Sometimes we ask candidates to do a one-minute video teaching us anything--how to sew, fish, cook. You can tell more about a person from those videos than by a résumé.
The Worry Score
We base our practice on the idea of proactive care. When we meet a patient, we assign him or her a worry score--a number from zero to 10. We start each day by huddling with the doctors, nurses, and health care coaches to see who is having problems. We focus on the 10s: "Is anyone in the hospital? Or in trouble with their blood pressure? Any ER visits last night?" We get data about patients whenever they see a specialist or visit the hospital, and we know when they fill prescriptions. If they don't, the health coach follows up to see why not, and how we can help. It's amazing what we learn: The pills were too big, or the patient has no way to get to the pharmacy. These are easy problems to solve.
Toward a New Medicine
In a typical practice, you're paid only for what you do. Every action has a bill code. Our business model is a flat per-patient fee, which ranges from $60 to $200 a month. Yes, we're about twice as expensive as other primary care practices, but we save money in the end because our focus is on keeping a patient well and out of the emergency room or surgery. The health coaches help us do that, and the flat fee lets them be creative--they can go grocery shopping with diabetic patients. If the doctor says, "Exercise three times a week for 30 minutes," the health coach can help make that happen, too. Their work can include going to people's houses or visiting them in the hospital, and then reporting back to the doctor if there is an issue.
How It Works
Our core proposition is to increase the funding that goes into primary care in a smart way. We work with sponsors--either self-insured employers, or unions that pay for health care, or progressive health insurers, most of which pay that monthly fee. We earn our money by taking care of our patients, not by billing for every service we provide, which is how the vast majority of primary care doctors are paid. Most big insurance companies and hospitals don't like us, because they make more money in the current model. At most, typical primary care accounts for 6 to 7 percent of the overall money spent on health care by patients, employers, and insurers. The rest is spent on failure of primary care. As a primary care physician, I want to get paid for actually taking care of patients.
Through our website, patients have full access to all their medical records, doctor's notes, and lab reports. They can book an appointment online, and choose it to be in person, by phone, or by video. We also ask patients to personalize their page--to put up a photo, and write a headline like, "Working dad wants to run a marathon." The best way to manage is to make sure each person has a goal-- and is acting on it.
Biology, Not Industry
Health care is not Starbucks. Health care is very local. Different populations require different things. Our clinic in Las Vegas works with casino workers, who have different needs from the members of the freelancers union in Brooklyn. For the carpenters union in Boston, we have a personal trainer. At Dartmouth, where we have a clinic on campus, we have more mindfulness and stress-reduction experts on that staff. Whenever we open a new practice, we send employees from one of our existing practices who understand our culture.
Most people think of scaling companies with an industrial model in mind, but health care is a people-based business. So we use a biological model. Cells scale through mitosis. A cell splits itself in two. And then those cells grow and split in two. That's how we plan to grow as well.