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SOAP Notes on the Business of Health Care: Iora Health

By Eva Luo | Tuesday, February 12, 2013
Eva Luo, an Open School learner and an MD/MBA candidate at the University of Michigan Medical School and Harvard Business School, wrote the following post for the IHI Open School blog about the innovative design of Iora Health, a primary care provider. To learn about other models to improve population health, check out our online course TA 101: Introduction to Population Health or check out the Open School's other educational offerings here.

The transition from medical school to business school meant one huge drastic change: I was no longer seeing patients every day. Given the unpredictable schedules and few days off during the third year clerkships, I thought I would welcome this change. However, I found the lack of patient interaction difficult to adjust to. I saw myself reacting inappropriately with excitement whenever classmates came to me for medical advice. I now welcome colds, skin rashes, headaches—anything I can get my hands on to evaluate. What I didn’t expect was to become my own patient and really flexing my primary care skills. I caught a cold only to be followed by an unrelenting post-viral cough that lasted until the end of the semester with a sprinkling of food poisoning and a still to be determined unknown but likely allergic rash. My body knew I missed medicine! 

With almost 20% of my business school cases being health care related, medicine has not completely left my life. My classes introduced several different frameworks used to think about creating the ideal customer experience for a given business. The foundations of business strategy are based on a deep understanding of customers and creating a value proposition for those customers. With that, all choices and trade-offs made in terms of business opeations, cost structure, defining the culture of the business, and anticipation of competition must fall in line with the core customers and value proposition of the business. After a semester’s worth of cases, if I had to choose an illustrative example in health care that provides excellent patient care with a sound business model, I would pick Iora Health. As a patient, I would happily seek medical advice at Iora Health’s clinics and would also be excited to work there as a physician.  

Iora Health is a Cambridge start-up led by Dr. Rushika Fernandopulle that seeks to revolutionize primary care delivery. Its goal is disrupt the current models of primary care delivery and reduce health care spending by placing a greater emphasis on primary care to prevent costly emergency room visits and hospital admissions. If this sounds familiar, Iora Health was highlighted in Atul Gawande’s New Yorker piece, “The Hot Spotters” two years ago.

Each clinic’s basic model revolves around three key innovations: a new model of care, different payment system, and development of a patient-centered electronic medical record system. Instead of traditionally funneling patients through brief interactions between nurses and physicians, each Iora Health patient is paired with a “health coach”. The health coach is often a community member chosen not for his or her clinical expertise, but rather strong communication skills, whose job is to stay in close contact with the patient at and between clinic visits through phone, email, text and video chat to track each patient’s progress and adherence to agreed upon health and wellness plans. Whatever concern or assistance a patient may need, the health coaches work with each patient to answer questions and achieve his or her goals. Each clinic typically has two clinicians and a team of eight health coaches. 

To pay for this customized and improved patient experience, each clinic partners with an employer with its own health plan. For example, one of the original sites in Atlantic City was partnered with the health-benefit programs of the casino workers’ union. The employer pays a flat monthly fee for each enrollee. In return, patients can visit the clinic as many times as needed without paying a copay at each visit. The clinic now also does not have to allocate valuable human resources to manage administrative activities like filing for claims for each visit. This overall allows providers to spend more time with each patient working on improving their health. 

While costs are double that average usually spent on primary care ($50-60 a month rather than $25-30), Iora Health’s new staff model of care has shown the ability to achieve an overall reduction in costs due to the prevention of costly ER admissions and hospitalizations. Its original site in Atlantic City had a 12.6% net spending reduction and 20% in Seattle. In just one year, its original sites were also able to demonstrate improved patient results with an average 48% drop in emergency room visits, average 50 point drop in cholesterol levels among those with high cholesterol, and 63% of smokers with heart and lung disease had quit smoking. It is not surprising that these impressive clinical results were accompanied by high ratings in service and quality by patients.  

Coordinating the work of the health coaches and clinicians is a new electronic medical records system. The user interface is intuitive and patient-centered in its design. Novel to Iora Health’s system is the ability for patients to both see and write in their own records.  

What has happened since Atul Gawande’s piece? Iora Health has brought its innovative model of care to three new sites in Las Vegas, Dartmouth College, and Brooklyn, NY. I visited Iora Health’s Brooklyn site last December after finals. Partnering with The Freelancer’s Union, Iora Health has created Collective Primary Care, a family practice created for individuals who receive health insurance through a Freelancer’s Insurance Company health plan

If the teal color scheme, yoga room and modern feel of the clinic were not strong enough signs that this was a very different primary care clinic, imagine this as a typical day. Every day begins with a forty five minute morning huddle. The two clinicians, health coaches and all other staff gather together to conduct a quick group relaxation exercise and discuss overnight hospitalizations, ER admissions, patients “in-crisis”, previous appointment no-shows, patients on today’s schedule, and the group class schedule of the day. These huddles are facilitated not by the clinicians, but on a rotating schedule involving everyone at the clinic. This creates a collaborative environment where everyone’s opinions are valued and no one hesitates to bring up concerns. 

Uniting the clinic together is an electronic patient tracking board displayed on a flat screen in the conference room and available on everyone’s laptop. The tracking board is a continuously updated Google document recording basic information such as check-in time, time in-room, time out of room, “ready for blood draw” status, and health coach and clinician assignments. The document can be updated by anyone. Additionally, unlike the siloed rooms found in a typical hospital or clinic only exacerbating interdisciplinary communication challenges, no one at the Brooklyn site has his or her own work office. Everyone works in either the large group conference room or on open high top tables scattered throughout the clinic. This facilitates constant communication between the clinicians and health coaches and adds to the notion of transparency between providers and patients. 

Most surprisingly, the patient waiting room is empty because patients are quickly greeted by a health coach upon arrival and the visit begins immediately. Health coaches see patients in exam rooms first discussing the patient’s agenda for today’s visit and any follow-up since the last interaction. The health coach then steps out of the room and discusses the agenda with the clinician briefly before the clinician and health coach reenter the room to greet the patient. At Iora Health, clinicians do not wear white coats. The clinician then reviews the patient’s agenda and delivers typical care including medical advice, a physical exam, and any referrals for laboratory or imaging tests or specialist care. The health coach will then wrap up the visit and will send a copy of the patient’s plan to him or her via email. The focus is completely on the patient’s experience. Running throughout the entire visit is a large monitor displaying openly to patients any notes written by the health coach or clinician. At each visit, the patient plays and is encouraged to have an active role. The most shocking aspect of the patient visit to me was that it was not restricted to fifteen minutes, but was allocated for an entire hour of the clinic’s time!

Since most of the patients I met were new patients (the clinic had only been open for three weeks when I visited), each patient left with a look of surprise on his or her face. Patients were impressed by the new model of care, their new active role, and simply by how comfortable the visit felt and how easy it was to gain access to their health coaches and the clinicians. One patient even said it was “refreshing” to finally be heard. I can only imagine by now that patients must feel like equal partners on their journey towards improved health. 

In reference to my strategy course, a successful business is one that truly understands its target customer and aligns its operations, cost structure and culture toward the value proposition promised to its customer. If one were to dissect our current health care system, all one would see is confusion. Some processes are designed with patients in mind, while others benefit only providers, and many have no clear customer in mind at all. The value chains are broken and interrupted at all levels of care from primary care through specialized surgeries. It is no surprise that poor strategy has led us to our current crisis of spending almost 20% of our GDP on health care with lackluster results in terms of mortality.

Iora Health, on the other hand, has built from the ground up a model with a mission to serve patients. Its day to day operations, cost structure, and culture all add to improved patient care. And as a side benefit, that patient care leads to reduced health care spending, improved patient outcomes, and increased provider satisfaction. While Iora Health currently has only a few direct competitors, from a social good perspective, it stands to win if local clinics adopt its model of care because then more patients will have access to a model of care that works.   


Subjective: Iora Health’s clinic culture is entrepreneurial, collaborative, and patient-centered resulting in happier patients and staff. 

Objective: In just one year, there was an average 48% drop in emergency room visits and a net spending reduction of 12.6% at its Atlantic City site and net spending reduction of 20% at its Seattle site. With 2 clinicians and 8 health coaches at each site, the Las Vegas practice sees over 800 patients and the Dartmouth practice sees over 600 patients. Just one month after opening its Brooklyn practice, the clinic enrolled over 400 patients. 

Assessment: Iora Health, a start-up founded in 2011, led by Dr. Fernandopulle, has created a primary care model that exhibits strong alignment of leadership, financial and operational systems to create a quality patient care experience at lower costs.

Plan: Main questions to consider for the future: 
  • Is this care model of a concierge like practice within a capitated payment system sustainable and the way of the future? 
  • Can and should this model be applied to clinical services beyond primary care? 
  • How will Iora Health expand in the next few years? Continue partnering with employers or begin to work with insurance companies? 
  • How will Iora Health balance its social mission with a return on cost-savings and revenue generation to its employer partners and investors?
  • With an eye on competition, how is One Medical Group different from the Iora Health model of practice? What kinds of choices does Iora Health need to make to remain competitive? 

References:

Thank you to everyone at the Primary Care Collective for allowing me to spend a wonderful day with you!

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