A Radical Rethinking of Primary Care That Could Make Everyone Healthier

Iora Health practices replace the general practitioner model with a hands-on health team.

National Journal
March 4, 2014, 2:47 a.m.

At 8:15 every week­day morn­ing, the Culin­ary Ex­tra Clin­ic team meets to talk about pa­tients its mem­bers are most wor­ried about. There are more than one thou­sand reg­u­lar clin­ic pa­tients in the Las Ve­gas area, most of whom work in hos­pit­al­ity jobs at the city’s ho­tels and casi­nos. All of the pa­tients are chron­ic­ally ill, and the team mem­bers dis­cuss those who are cur­rently in the hos­pit­al or have just been dis­charged. But they also fo­cus on oth­er, less ob­vi­ous, con­cerns.

The team — which in­cludes doc­tors, health coaches, a so­cial work­er and a be­ha­vi­or­al health spe­cial­ist — might brain­storm a way to pay for an ex­pens­ive test, like an MRI, that a pa­tient can’t af­ford. They might de­cide to take a pa­tient to the gro­cery store. Last week, they chose to soothe a hos­pit­al­ized pa­tient’s over­whelmed wife by get­ting her a mas­sage. Car­o­lina Pavese, the head nurse, says of the team’s ap­proach: “If that’s go­ing to make it bet­ter, let’s do that.”

The clin­ic prac­tice is run by Iora Health, a Cam­bridge-based start-up that be­lieves it can make pa­tients health­i­er at a lower cost by in­creas­ing ac­cess to ba­sic health care ser­vices and by think­ing more broadly about what ba­sic ser­vices should be. “We of­ten say, our job is not to im­prove people’s health,” says founder and CEO Dr. Rushi­ka Fernan­dopulle. “Our job is to im­prove people’s life. And that will im­prove people’s health.”

Na­tion­ally, sev­en of 10 Amer­ic­ans die from chron­ic dis­eases — primar­ily heart dis­ease, can­cer, and stroke. Low-in­come and minor­ity groups tend to have high­er risk factors for those dis­eases, like high blood pres­sure, ac­cord­ing to a 2012 stat­ist­ic­al up­date from the Amer­ic­an Heart As­so­ci­ation. The up­date also found that Afric­an-Amer­ic­ans and His­pan­ics were less likely than whites to re­ceive all the sug­ges­ted care for ad­dress­ing those risk factors. 

“Iora health was nev­er meant as a health-dis­par­it­ies re­duc­tion ef­fort, but it turns out that ac­tu­ally by do­ing primary care right — which we do — you are ac­tu­ally able to re­duce dis­par­it­ies con­sid­er­ably,” Fernan­dopulle says. A prac­ti­cing primary care doc­tor and former health-care con­sult­ant, he foun­ded Iora Health in 2011 be­cause he wanted to re­in­vent the way ba­sic health care is de­livered. 

Typ­ic­ally, says Fernan­dopulle, primary care ac­counts for about 5 per­cent of total health-care spend­ing. Iora Health asks in­sur­ance com­pan­ies spon­sor­ing a prac­tice to double that amount. The com­pany also pays doc­tors fixed salar­ies, a change Fernan­dopulle says leads doc­tors to re­cog­nize that “my job is to take care of this whole pop­u­la­tion, and to help them no mat­ter what it takes.”

Iora health-care teams are also or­gan­ized very dif­fer­ently than the av­er­age med­ic­al of­fice. A typ­ic­al Iora Health prac­tice in­cludes two doc­tors, a nurse, a so­cial work­er, and more than a half-dozen health coaches. Each pa­tient is con­sidered the re­spons­ib­il­ity of the en­tire team. De­pend­ing on the ser­vices pa­tients want and need, ad­di­tion­al health-care pro­fes­sion­als might round out the team — a nu­tri­tion­ist, say, or a per­son­al train­er.

Iora Health pa­tients can drop by without an ap­point­ment, and they are en­cour­aged to stay in touch with health coaches and doc­tors by email, text mes­sages, phone calls, and video con­fer­en­cing. The com­pany hires staff who speak the lan­guages and re­flect the cul­tur­al back­grounds of the pa­tients they serve. At the Culin­ary Ex­tra Clin­ic, where 73 per­cent of pa­tients are His­pan­ic and the av­er­age age is 56, pa­tients tend to fa­vor face-to-face meet­ings and phone calls.

This new ap­proach to health care re­quires part­ner­ing with in­sur­ance pro­viders will­ing to pay more for primary care. The Culin­ary Ex­tra Clin­ic is sponsored by the Culin­ary Health Fund, a plan that cov­ers mem­bers of the loc­al culin­ary work­ers uni­on and their de­pend­ents. “It was ex­pens­ive for us in the be­gin­ning,” says Kim Voss, seni­or dir­ect­or of health care net­works and ad­vocacy at the Culin­ary Health Fund. “But it was a long-term com­mit­ment to im­prove par­ti­cipant health and to be fisc­ally re­spons­ible.”

Oth­er prac­tices — such as a clin­ic for Dart­mouth Col­lege em­ploy­ees in Han­over, N.H., and clin­ics for mem­bers of the Freel­an­cers Uni­on in New York City — serve all adults covered by the spon­sor­ing in­sur­ance com­pany. Be­cause they tend to serve health­i­er pop­u­la­tions, those prac­tices can reach many more pa­tients.

Culin­ary Ex­tra Clin­ic pa­tients are gen­er­ally happy cus­tom­ers. Ar­range­ments with in­surers guar­an­tee that pa­tients don’t have to pay out of pock­et for any care they re­ceive at an Iora prac­tice. “They take care of everything you need there,” says Al­fred Flores, 73, a re­cent re­tir­ee who worked as a cook at the Stra­to­sphere, a hotel and casino on the Strip, for al­most two dec­ades. The only down­side, he says, is that wait times for ap­point­ments can some­times be long. Doc­tors and health coaches take time with their pa­tients, and the large num­ber of walk-ins makes each day’s sched­ule un­pre­dict­able.

Flores also likes the fact that Culin­ary Ex­tra Clin­ic staff greet him with hugs and they know every­one by name. Clin­ic staff are also aided by a soft­ware sys­tem that alerts the team to signs of trouble, like when a pa­tient fails to pick up his med­ic­a­tion, so they can reach out with as­sist­ance. Per­haps more im­port­ant, each pa­tient has a health coach who serves as a listen­er and a guide. Health coaches per­form some ba­sic clin­ic­al tasks, such as tak­ing vi­tal signs, but many have no form­al clin­ic­al train­ing. They’re se­lec­ted for their em­pathy. Some­times, pa­tients will stop by just be­cause they want to talk, says Yan­ell Nava, a nurse and health coach at the Culin­ary Ex­tra Clin­ic. Of­ten, it turns out that seem­ingly un­re­lated cir­cum­stances in a pa­tient’s life are af­fect­ing his or her health.

It’s too early to tell wheth­er the Culin­ary Ex­tra Clin­ic is im­prov­ing health and lower­ing costs, Voss says. But evid­ence from an At­lantic City, N.J. clin­ic that Fernan­dopulle es­tab­lished along the same mod­el be­fore he foun­ded Iora sug­gests that it might. In 2009, pa­tients en­rolled in the At­lantic City chron­ic-care clin­ic ex­per­i­enced 48 per­cent few­er emer­gency room vis­its and 41 per­cent few­er hos­pit­al ad­mis­sions than a com­par­able pop­u­la­tion, ac­cord­ing to an eval­u­ation by Dr. Nit­eesh Choudhry, an as­so­ci­ate pro­fess­or at Har­vard Med­ic­al School. Health care costs for the At­lantic City group were 12.3 per­cent lower over­all than for the con­trol group.

And all At­lantic City pa­tients ex­per­i­enced re­duc­tions in blood pres­sure, cho­les­ter­ol, and blood sug­ar levels. Afric­an-Amer­ic­an and His­pan­ic pa­tients ten­ded to enter the prac­tice with high­er levels of all three than their white and Asi­an-Amer­ic­an coun­ter­parts. “Six months after be­ing in the prac­tice, those dis­par­it­ies pretty much van­ished. You couldn’t tell the dif­fer­ence,” Fernan­dopulle says. 

Iora Health is privately fun­ded by ven­ture cap­it­al funds and sev­er­al private in­vestors, in­clud­ing Tony Hsieh, CEO of the Las Ve­gas-based Zap­pos. The com­pany isn’t yet prof­it­able but it’s already suc­ceeded in prov­ing that a cul­ture shift in health care pro­vi­sion is pos­sible. “In health care, we’re here to do the right thing for people,” says head nurse Pavese. “If you start with that and stick to it, then good things hap­pen for them and every­one around them.” That ap­proach, she says, has re­newed her faith in her pro­fes­sion.

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