December 3, 2020
Talking with Iora Health, an Innovative Primary Care Provider
by Alexandra Olgin, Michael Cuello, and Teresa Breen
Gist Healthcare Daily host Alex Olgin recently sat down with Rushika Fernandopulle, MD, Co-Founder and CEO of Iora Health. They discussed how the innovative primary care provider has evolved during the pandemic to provide seamless, relationship-based care across multiple care channels (blending in-person visits with video visits, phone visits, and asynchronous encounters) as well as what the future of value-based care may hold. Listen to an audio interview on our podcast here and check out the below for a summary of the conversation.
Rushika Fernandopulle, MD is a physician who has spent decades improving the quality of healthcare delivered to patients. He was the first Executive Director of the Harvard Interfaculty Program for Health Systems Improvement and served as a Managing Director of the Advisory Board Company. He serves on the faculty and earned his AB, MD, and MPP from Harvard University. He completed his clinical training at the Massachusetts General Hospital. He is the currently the co-founder and CEO of Iora Health, a Boston-based company delivering value-based care in a human-centric way to thousands of Medicare patients around the US. The company’s mission is to restore humanity to healthcare and provide wrap-around primary care services to a growing and higher cost population: seniors.
Our dialogue with Rushika Fernandopulle MD, Co-Founder and CEO, Iora Health
Founding Iora Health
Gist Healthcare: Can you tell us the story of how you came to start Iora?
Rushika Fernandopulle, MD: I’m a practicing primary care doctor, and it’s really hard to be a practicing physician or a patient and not realize that the healthcare system we have is screwed up. While good people have good intentions, the system of how we do it is wrong.
My central insight was that maybe this system is rotten to the core, and what we need to do is simply start over. What we need to do is build a system based on relationships and not transactions. And, unfortunately when you start saying that, you realize you have to change everything—the payment model, the staffing model, the process, the IT platform, the space design—you start unraveling the thread and the whole garment falls apart.
We started about 15 years ago, before anyone gave a whit about primary care or anyone else was funding this sort of thing. I ended up building a practice in Arlington, Massachusetts called Renaissance Health. We wanted to try to build a new vision of where we wanted to go. About 10 years ago, we decided to do this at scale, and at that time people were starting to fund to these kinds of startups. So we raised some capital and started Iora, with its mission to transform healthcare. Nothing less—not to build a practice, and not to make money—but to transform healthcare. And the way we transform healthcare is by building a better mousetrap, letting the customers vote with their feet, and shaming the healthcare system into doing something.
Delivering primary care in a COVID world
GH: How has Iora adapted to care for patients during the pandemic?
RF: Our reimbursement model is 100 percent value-based payments, so we were never forced to only see patients in person to get paid—we get paid no matter how we see a patient. We have always been able to interact with our patients by telephone, email, text, and video in addition to in-person visits.
When COVID hit, we just had to turn the volume knob up on patient interactions outside of office visits. In the first few weeks of the pandemic, we did only eight percent of our total encounters in person and the rest were all via video, telephone, e-mail and text. We still kept all of our practices open though, because we did need to care for some patients in-person.
Our current patient encounter breakdown is roughly 50 percent in-person, 40 percent video, and 10 percent by phone. And on top of that we’re doing almost an equal number of asynchronous encounters via email or texts.
GH: And how has the balance of virtual and in-person care evolved as the pandemic has progressed?
RF: While we have swung the pendulum back a bit, a lot of organizations have swung it all the way back to try to get 90 percent of their visits in-person. We don’t think that’s the right answer. The way most people in healthcare are set up is fragmented. There are companies like Buoy, which only do chatbots. There are companies like Teladoc, which only do telephone or video visits. There are some physician practices that only see people in person. There are companies like Landmark that only see people in their homes. That’s a bad way to organize healthcare because the same person needs to be seen a lot of different ways, depending on their needs. It’s not like some people only need to do video visits and that’s all they’ll ever do.
We need to organize around the patient, not the visit type. Our current patient encounter breakdown is roughly 50 percent in-person, 40 percent video, and 10 percent by phone. And on top of that we’re doing almost an equal number of asynchronous encounters via email or texts.
Redesigning care around the patient
GH: How is Iora providing a seamless care experience across multiple modalities?
RF: Because we can ignore fee-for-service payment constraints, we have a great opportunity to design around the right way to care for each patient. Some patients will want virtual care, but not for everything. There are times we should do that and it should be integrated deeply into the care journey. But 30 percent of our seniors actually have trouble doing video visits with us. Either, they don’t have the right internet bandwidth, connection, plan, device, etc. or there’s some cognitive issues. We believe it’s our job to fix these issues when we can.
The digital divide shouldn’t be a barrier. We’ve tried a number of things: for some people we can just preconfigure a tablet and mail it to them; for other people our health coaches actually go and deliver a tablet to patients, providing in-person tech support; and for others, we may go on a Saturday so a family member can also join and help. It makes sense to give people a tablet, given the cost of an ER visit. It’s because we’re in these global payment models and on the hook for total cost of care, that we can do this kind of thing.
GH: How are you staffed to provide this kind of care?
RF: Instead of organizing around physical offices, which is the obvious way to do it, we have care teams organized around patient populations.
In our care model we have an Iora team managing a population of around 600 or so patients. Each team has a doctor, three health coaches and an operations assistant. Their job is to improve each patients’ health, keep them out of trouble, and do whatever it takes. Some of that is seeing patients in person, but a huge part of what they do—70 to 80 percent—is seeing them by video or telephone, emailing or texting them, calling their specialists, etc. This model allows us to be flexible in how we meet the needs of our patients and really organize around populations instead of around physical space.
Creating a care model centered around value
GH: Iora focuses mainly on the Medicare Advantage population. Do you have plans to expand beyond that population?
RF: Our model is a relationship-based, primary care model for patients who are older, sicker, and who we can manage for a long period of time. When we first get patients, we may actually increase their healthcare costs because we provide them with more services. We need to keep them long enough to see the benefits of that, and that may take two or three years.
We’ve started the core of our business in the Medicare Advantage space so that we could get global risk contracts. We are going to expand and begin seeing original Medicare patients through the Center for Medicare and Medicare Innovation (CMMI) Direct Contracting model starting in April 2021. We have always also served some select, self-insured employer populations who have older and sicker workers, geographic concentration, and long-term workforces. As we find ways to get the right business model that fits us, we will take on more populations.
GH: How have your partnerships with payers evolved?
RF: We do what we call high-impact, relationship-based care. Obviously, it’s a partnership between provider and patient, but it’s also a partnership between provider and payer. Due to the zero-sum nature of fee-for-service reimbursement, providers and payers have traditionally had pretty adversarial relationships. But if we move to the value-based framework, providers and payers actually want the same thing for our customers: better care, better satisfaction and lower cost of care.
Iora has really great partnerships with health plans, which truly act more like partnerships than contracts. They’re long-term; for example, we have a ten-year contract with Humana. Several health plans, including United, Humana and Tufts are actually also investors in Iora. And we are increasingly partnering with more, including WellCare and Blue Cross Blue Shield in North Carolina.
This whole talk about value-based care is a red herring—value-based care is really important, but it’s a means to an end. The thing we have to do is redesign healthcare in order to make it better for consumers.
GH: What do you see as the future of value-based care?
RF: This whole talk about value-based care is a red herring—value-based care is really important, but it’s a means to an end. The thing we have to do is redesign healthcare in order to make it better for consumers. Organizations that do so will win because consumers vote with their feet. It’s really important to do value-based care in order to pay for it, but if all you do is try to make more money off it by doing the same thing and somehow gaming the contracts, then it’s a waste of time.
GH: So, if value-based care is just a means to an end, what does the “end” look like?
RF: The end is making people healthier. In the end, if we don’t actually make people healthier, this is all a waste of time. We need to change how actual people get actual care and that’s about building relationships. It’s about focusing on things that have nothing to do with healthcare. The things that matter to people aging well include optimism, a sense of purpose, and social connections. So, that’s what we need to be doing in healthcare, not just doing more tests on people, giving them more drugs, etc. That’s not how we fix the problem. Primary care is a great lever to both help with that upstream stuff and helping people navigate the downstream.
What we need to do is fundamentally change the production process of care. We have been increasingly moving to global risk models where we have responsibility for total cost of care, and that gives us the freedom to decide how we serve patients. No one tells us what we get paid for, and that allows us to do adapt to things like COVID by rapidly iterating on the model and changing it as needed.