| 5 August 2016
Dear Interested Readers,
Inside This Week’s Letter
This letter is not about the ongoing presidential campaign. After two weeks of focus on the political conventions it is time to think about other things. That is easier said than done, given the continuing reverberations following the emotionally wrenching presentation by Khizr and Ghazala Khan, the parents of Captain Humayun Khan who died while protecting his men in Iraq in 2004. The 2016 election has become a spectacle that occupies more of my attention than it should. It is hard not to immediately go to the headlines on the front pages and political opinion columns on the op ed pages of our major newspapers every morning looking for a new bit of information. Even Facebook has more politics than cute kitten pictures, but just because I can’t stop looking should not be my justification for boring you with my thoughts.
I am sure that many of you do the same thing in the papers and online every morning so I am quite sure that there is little that I can add to your understanding of the ongoing controversy. It is still three months until the election and I am confident that there will be good reason to return to it if and when something pertaining to healthcare comes up, but not this week. In this bizarre year when so many voters are angry there is still a real possibility that either candidate could win. I believe that the final result will be the outcome of some event or some misstatement that has not occurred yet and could involve either candidate. I hope and pray that when that event occurs it will be some verbal event; a revelation of an unacceptable opinion to most voters like Mitt Romney’s taped comment about the 47 percent. I hope the event that tips the scales to either candidate is not some act of violence in this country or abroad.
Now that you know what the letter is not about, let me tell you what it does cover. It is a return to Dr. Ebert’s quest for an operating system and finance structure that will support the Triple Aim, or if you prefer, the Triple Aim Plus One. For sometime I have been intrigued by the innovative primary care start up, Iora Health. This last week I visited Iora’s headquarters on Tremont Street in the heart of downtown Boston. It was a fascinating experience that I want to share with you. This will probably be the first of two letters that examine what is going on at Iora. The second letter will follow a visit that is coming up in about ten days to the Iora practice near me at Dartmouth in Hanover, New Hampshire. I hope that you will enjoy this piece and that it gets you thinking and looking forward to the next installment about Iora which will be in the letter for August 26.
If you have finished that exciting summer novel that you have been reading a few pages at a time for the last two months and are looking for something a little different to read, let me recommend taking a glance at strategyhealthcare.com. I derive a strange pleasure from reading old posts. No posting on SHC is more than 2000 words! These weekly letters are often twice as long. There are no metaphors from the world of sports or references to fishing or exercise! The posting that went up on Wednesday contained the core message from last Friday in half the words. The site is searchable and also gives you access to the archives for the Friday letter if you want a sports reference or encouragement to take a walk. Trust me. Checking out SHC once a week would be a good routine to try because every week there is something new there for you.
It Seems So Logical!
Regular readers of these notes may remember that the main portion of my letter on July 8 was entitled “It’s Not An Easy Ride To The Future On The Magic Carpet of Innovation”. If you do not remember the letter and want to review the shorter version, you can click here and immediately connect to it. I was delighted when just a few hours after the letter went out an “Interested Reader”, Dr. Marc-David Munk, the Vice President, Accountable Care and Senior Medical Director for Medicare Practices at Iora Health wrote back,
Hi Gene- another great column. Would love to have you come and visit Iora the next time you’re in Boston. We have been developing a very creative care model in an all-risk environment.
Have a great weekend
Marc
Marc and I first met when he became the CMO of Reliant Medical Group while I was still the CEO of Atrius Health. I was delighted to learn of his position at Iora and that he writes his own informative blog, American Healthcare Blog. The tagline for Dr. Munk’s blog is: “Notes From the Frontlines of Risk-Bearing Medicine”. The most recent post begins with the documented observation of the breakdown of the social contract between colleges and their alumni. He projects that the same process is occurring in healthcare. I think that he is right. His conclusion is succinct:
This [the shift from a broad donor base of alumni] won’t be an issue of declining philanthropy: A few massive donations from a handful of benefactors will make up the gap. The bigger long term issue for healthcare systems is declining consumer loyalty. The erosion of the organization/ patient social contract can only lead to a future with fewer brand-name consumers and more buyers shopping for deals while “interlining” between systems (a trend that I wrote about last year). Cost (or the ability to save a couple of bucks in a high-deductible plan) drives point-of-care decisions, for sure. More important (and more insidious ) is the way that high cost/low value care impacts how patients feel about the patient/healthsystem relationship.
After the exchange of a few emails I was delighted when we were able to set the visit for last Monday, August 1. The plan was that he would show me around their home office in downtown Boston and 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.
[Iora is a species of beautiful little birds found in India and Southeast Asia. Dr Fernandopulle was born in Sri Lanka and moved to Baltimore as a child.]
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. Dr Gawande commented in a subsequent piece about his objective in the article and what skeptics were saying.
It’s a strategy, being tried in places like Camden, Atlantic City, and Boston, of focussing on the sickest five per cent of patients, who account for sixty per cent of health-care costs.
The article was an exciting read for someone like me 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 was a pretty complete picture of the salient features of the Iora Health approach. Of the 10,000 words in the article Gawande spent more than 2500 describing the unique approach that Iora was using to lower 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.
- Year after year, the low-wage busboys, hotel cleaners, and kitchen staff voted against sacrificing their health benefits. As a result, they have gone without a wage increase for years.
- 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 patients were given unlimited access to the clinic without charges—no co-payments, no insurance bills.
- 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…”
This intensive approach does make a difference. ER visits were reduced more than 40%. Patients were better; remarkable improvements occurred in the control of blood pressure and cholesterol. The patients were also markedly healthier. 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.
This success did not go unnoticed or unresisted. Remember, as discussed in the July 8 letter, innovation is part of a process called “creative destruction”. 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. That resistance added cost and resulted in longer hospital stays. Attempts to direct patients to “preferred doctors” resulted in efforts at retaliation. Patients in the ER were pressured to move away from the system. 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. Most impressive is the use of culturally competent health coaches and the full integration of behavioral health into primary care. It now has practices in Hanover, Medford, Dorchester, Hartford, Brooklyn, Chicago, three sites around Seattle, three sites around Denver, Las Vegas, Tucson, Phoenix, and 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. Two practices cofounded with Tufts Health Plan are focusing on Medicare Advantage patients. Dartmouth College is a partner in a practice that is limited to its own employees. The Dorchester practice is a partnership with the New England Carpenters Benefits Fund. Humana is the partner in Washington, Colorado and Arizona.
As you may also remember from the July 8th letter, 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, Dr. Fernandopulle has cleared that huge barrier. In a very informative set of interviews published by the Harvard University Center For Primary Care he very effectively addresses the issues of finance, including the support of venture capital, and the for profit status of Iora. If you have an interest in learning more you should read the interviews.
The first interview explores the history of Iora and Dr. Fernandopulle’s personal history and philosophy. It is a fascinating conversation that traces the development of Iora as it evolves and matures from concept to reality. 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. That’s who we work for, that’s who in the end pays us. 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. So when you build that sort of a culture, change comes from top-down, where the top is the patients, or the health coaches, or the people in the practices. People closest to the care come up with all the good ideas, not us. We just need to allow it to happen.
- And that’s what I think is a big problem in health care in general, and maybe health care in Boston in particular—it is so “authority-centric.” …
- 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. There are plenty of big not-for-profit institutions for which it’s not clear they are looking out for people...For us, our tax status is a tactical decision. Transforming healthcare is a huge problem. If we want to do it right, we need real capital—to be able to get to scale and to attract people and build technology. So that’s why we’re doing what we’re doing. It seems to be working so far...I think the principle is: be creative. Why not try things? The thing we’ve been able to do—more than anything that we do—is just create a different culture. And the culture is: try anything. Try anything tomorrow. Not in 6 weeks, not in 6 months. Don’t study it. Just do it and see if it works or not. Obviously be safe and don’t do crazy things, but the bounds of what you should do are pretty broad.
- Our mission is: Transform health care. We’re going to start doing it by just doing it, and letting patients vote with their feet...I would love it if there were a thousand people like us. It’s a $3.5 trillion industry. We’re never going to be more than 1% of it, but we hope that our being alive and doing well will convince lots of other people to follow behind.
- 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. People say to us, “you’re rebuilding primary care,” but what we’re really doing is a series of experiments...We have 13 practices now; it’s going to be over 20 soon. 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. As opposed to penalizing people for them, because if you do, you will never create a culture where people feel like they can try. We don’t just stop at naming the failures. 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. And that we’ll never do it again. Esther Dyson has a great motto: “Always make new mistakes.” You can fail once, many, many times, but never fail twice at the same thing. Because then you’re not learning.
A quick Google search will reveal that many healthcare writers have been fascinated by Dr. Fernandopulle and Iora. One particularly good article is from the Boston Globe last year. I had done my research before the meeting 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. It 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. Growth could be curtailed by a limited supply of professionals who want to work in an innovative practice.
I have not adequately focused on the role of behavioral health. Every patient has almost instant access to behavioral health resources. The complete integration of behavioral health is optimal, but will there be an adequate supply of behavioral health specialists in the future?
My goal in this two part system was to introduce you to Iora in this letter. After my visit to the Dartmouth practice I plan to focus on the similarities between Iora and 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 the July discussion I mentioned that in an established system today’s work work makes innovation almost impossible. Conversely, in the innovator’s world, integrating what is new with what exists inevitably produces conflicts as “creative destruction” becomes a reality. Years ago I imagined HCHP as an “island economy”. As long as we were an isolated pioneer outpost and there was a spirit of adventure, life was less stressful. We were not concerned with our work load or our compensation. We were happy exploring a better way.
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 who 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. The number of similarities are astounding from the fascination with prepayment, to the redesign of the concepts of an optimal practice, and the attempt to create a more clinically useful medical record.
I was impressed by how “intuitively Lean” the Iora model is. The daily huddle and the upside down nature of the practice are Lean objectives that often take several years to master. Iora has done it virtually on day one. 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.
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. I am eagerly awaiting my next exposure and can hardly wait to describe to you what I discover. 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.
It’s August. Are You Making The Most of Every Beautiful Day?
A little more than a month ago my wife and I enjoyed the wedding of the daughter of friends in Beacon, New York on the Hudson River which is reachable from New York City by commuter rail. The Hudson River seems a mile wide at that point and it is easy to understand how old Henry Hudson thought that he might have found a passage through to the orient. As the picture in this week’s header shows, about 150 miles north of Beacon and a few miles west of Lake George, the Hudson is not that wide this time of year. Old Henry could not have gotten this far upstream in a canoe, but I did see people coming downstream in tubes as they interrupted my fly fishing just in front of that outcropping of stone in the middle of the picture. One of the joys of retirement is fly fishing on a Wednesday afternoon.
We were visiting the Lake George area to see some old friends. Even for those of us who are retired the number of beautiful summer days for this year are dwindling down fast to a precious few. I hope that you will find your way into the wider world this weekend and save all the viewing of the Olympics to the evening summaries that will be available for your catch up viewing pleasure.
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| Be well, stay in touch, and don’t let anything keep you from doing the good that you can do every day,
Gene
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