COVID-19 Reset

There might not be a specific moment when we can hit the reset button and start to tackle systemic healthcare challenges with a clean slate, but smaller resets are already underway. Join us as we examine what a COVID-19 Reset looks like for doctors, nurses, and other healthcare professionals.

In this episode, we spoke with Dr. Rushika Fernandopulle, founder and CEO of Iora Health, about how physicians have addressed the pandemic in their own practices and the changing perceptions around value based care. We also spoke to Dr. Dan Knecht and Angie Meoli, for insight into how CVS is changing its own systems.

One of the most eye-opening impacts of COVID-19 has been the dramatic disparities highlighted in our healthcare system. Dr. Dela Taghipour and Dr. Nadia Abuelezam will discuss how we can collectively reimagine community healthcare to address those disparities.

What is Healthy Conversations?

Healthy Conversations brings together leaders and innovators in health care to talk about the biggest issues facing patients and providers today. Every month, we explore new topics to help uncover the clinical insights and emerging technologies transforming health care in real time.

Speaker 1:
Thinking bigger, much bigger.

Dr. Rushika Fernandopulle:
We need to change this. We need to fix this. We need to fit a new model of care delivery.

Speaker 3:
Going to the experts for finding the gaps.

Dr. Daniel Kraft:
How do you end up connecting that data so it's useful?

Speaker 1:
We take back medicine.

Dr. Rushika Fernandopulle:
We can dramatically improve outcomes.

Dr. Daniel Kraft:
Welcome to Healthy Conversations, the podcast and open discussion amongst health care professionals about the latest innovations, what we've learned on the front lines of the pandemic, and how our industry is changing in real time. I'm Dr. Daniel Kraft, and here in conversation today with Dr. Rushika Fernandopulle, the founder and CEO of Iora Health. Hey Rushika.

Dr. Rushika Fernandopulle:
Hey Dan. It's great to see you again.

Dr. Daniel Kraft:
And to see you. I mean we go way back. Seems just like yesterday we were Interns at Mass General Hospital in Internal Medicine. The world's changed just a little bit, but in some ways it hasn't. And you've certainly, since we've known each other, done a lot to catalyze and transform health care. I thought, just as a level set, maybe share a little bit of your health care journey since we were residents together and how you ended up founding Iora and how it works a little bit.

Dr. Rushika Fernandopulle:
Sure. So as you know, I'm a primary care doc and was in a typical primary care practice. And thinking the realization that the way we're doing this despite largely good people and largely good intentions, wasn't working. It was fragmented. It's reactive. It's poor experience for patients and for doctors. The outcomes are poor. It's embarrassingly wasteful. There are huge disparities. I remember actually a moment at Mass General where I was seeing patients and really busy, running like a hamster on a wheel. There are the new really crappy HR that they put in that made the doctor be the code monkey.
I remember staying late after work for two hours on a February night in Boston while my family was having dinner at home, and I was finishing my charts and a colleague looked at me and she'd said something very profound. She said, "Rushika, every day I lose a little piece of my soul." Every day I lose a little piece of my soul. We came into this to help people. They come to us with such big needs and yet, the system doesn't let us do it. And this is the kicker, it's getting worse and not better. And I think, that's when I decided, "We need to change this. We need to fix this."
We need to create a new model of care delivery that was focused, really on health and not on doing more stuff to people, that was really consumer-centric, had a great clinical model, leveraged technology the right way. And, I realized to do that we had to just simply start over. And I think we've learned a ton on this journey. And, just a couple things. One is, the payment model has got to be different. We do not work in what's called fee-for-service, which is how most health care works, where you get paid per thing you do. Guess what that does? That encourages you to do more things to people. It actually, ironically, discourages you from making people healthier.
Number two then completely changed the delivery model to really help consumers execute on their plans, right? But, what you and I do as docs is, we tell people what to do. That's mildly interesting, right? People come to me in my office and I will say in my seven-minute visit, "You Dan, should eat less, exercise more, take your medicines. Good luck sucker. I'll see you in three months." And you come back in three months. "You bad, bad, non-compliant patient," right? No, we need to help people actually do this.
And we've evolved a team model with not just docs but health coaches from the community, picked for empathy, hold people's hands when that's the right thing to do, kick him in the behind, when that's the right thing to do, integrate behavioral health. Interact not just in person but by email, and text message, and video chat. Have patients get together in groups, be reactive and proactive. Really, a completely different model.

Dr. Daniel Kraft:
Have you been able to measure even just the clinician satisfaction in that practice environment?

Dr. Rushika Fernandopulle:
Yeah. So, we track what we call quintuple aim. Actually Dan, we've added one. So, they're a thing called triple aim that Don Berwick and I at HI came up with, which is, the goal of health care ought to be better patient experience and then, better clinical outcomes, healthier people. And then, lower the total cost of care, because we know how much waste there is. Then, people have added over time, a fourth thing we call quintuple aim, which is joy in practice. And we've added a fifth, which is, it needs to be economically sustainable, right? So, quintuple aim.
So, we actually can show that we impact all five of those things, right? So, patients really like this. They come to us in droves, they stick with it. This is a much better patient experience. We can dramatically improve outcomes. We can improve people's health. We can improve diabetes care, and hypertension care, and the like. We're operating in the 90, 95th percentile in all of those. We can dramatically lower the cost of care. The total cost of care is down by about 20%, two zero percent, largely through driving down unnecessary hospitalizations.
And again, we can talk about why hospitals may not like this if you're making money out of filling hospital beds. But to be quite honest, if you're looking after the consumer, being in the hospital when you don't need to be isn't a really good thing. Hospitals are really dangerous places. If you need to be there, by all means you should be there. If you don't need to be there, you should not be there, right? You should be somewhere else, anywhere else.
Fourth is joined practice, as you mentioned. Our clinicians, both doctors, nurse practitioners as well as other people on the team really liked this. I remember early on Atul Gawande, the great New Yorker writer, came to visit one of our practices in Atlantic City, and he sat in on one of our huddles. And the first thing he noticed, he wrote me note on a piece of paper, handed it to me like, "Oh my god, people actually look happy here." Which is shocking in a primary care practice in this day and age. And why? Because, they're able to do the job that they trained to do. Again, the opposite of, "Every day I lose a piece of my soul." And then finally, we can really make the economics work if we can get the payment model right.

Dr. Daniel Kraft:
What I think fascinating is your team approach. Yeah, you can't just give someone a pamphlet and say, "Exercise more, eat less." And so, you've really integrated in coaching. Maybe describe how that works and how that's maybe evolved over the last few years.

Dr. Rushika Fernandopulle:
Yeah. So, it's a really important part. Again, this is really an important difference. In the typical primary care model, typical health care model, I, the doctor, get paid for simply telling you what to do. Yeah, "Eat less, take your meds, and good luck sucker." I file a claim for that. I get paid. I actually don't give a wit whether you do it or not. And actually, perversely, I don't really want you to do it, because if you do it and you're healthy, then I stop getting paid. That's not what we should work for, right?
Last I checked, I took an oath to serve my patients, not the health plan, not the hospital. That's who we should be working for. We need people to help engage with consumers. The first and most important thing they do is, they build relationships, right? This is all about behavior change. And, people change behavior not because some computer tells them or they read a pamphlet, they change it because someone they care about wants them to. And now, just being partners with the patient to then help them on their journey.

Dr. Daniel Kraft:
So in health care you get what you incentivize, whether it's giving more pain meds or preventing readmissions. What do you incentivize? Is it hemoglobin A1Cs, or less admissions, or better blood pressure control? At least for your whole clinical team, what keeps them at the top of their game?

Dr. Rushika Fernandopulle:
I actually think people use money to incent behavior when they can't control culture, right? I think the best medical groups in the world, the Mayo Clinic, Cleveland Clinic, people like that, they have decided, "We're going to control behavior through culture." The problem with using money to try and incent behavior is, there are all sorts of unintended consequences for complex behavior and doing health care well is incredibly complex. Quintuple aim, they sometimes feed off each other, teaching the test, all of these problems, I am petrified at trying to put in place really blunt financial instruments.
So what we do is say, "We're going to pay you a fair salary. We're going to give you a ton of data how you're performing. We're going to let you compare yourself to other people," right? By the way, as you know, doctors are very competitive. They don't want to be at the bottom of the table. They will work hard. But, we don't tie money to it because the second you tie money to it, people start arguing about the data. And we say, "No, we're going to control culture." By the way, if you are not doing the right thing, the culture will spit you out.

Dr. Daniel Kraft:
So, have you learned what to measure in a sense, to help move the needle in terms of outcomes since you really are value-based?

Dr. Rushika Fernandopulle:
So, we have what we call the seven drivers of our business, which we measure, right? So if we're going to be successful, what are the things? We need those tied to the quintuple aim, right? So you go to the quintuple aim, you go back, what are the seven drivers? And those are things like retention rate of patients, really important, growth rate. You would have to do a hospitalization rate. How often are people ending up in the hospital? Our referral rates. It has to do with our team retention rates. Then, each one of those drive back to one of the things that actually predict that, right?
So, I think it's really important to have it. You would be really careful, A, not to pay attention to any one variable because you have to look at them in totality. And number two, you would be very careful not to use too short-term an impact, right? You've got to think about this long-term. So again, data's really important. You've got to remember the reason you're doing it, use the data to identify hypotheses, but not to try and answer the question.

Dr. Daniel Kraft:
That's spot on. I mean, now the trick is, many clinicians are overwhelmed by data. Any lessons for folks listening about how to start thinking about the technology piece and how you do the clinical workflow?

Dr. Rushika Fernandopulle:
Yeah. So by the way, as you know, there's a huge epidemic of physician burnout going on right now. And, a lot of people blame the EMR, right? So, it's the electronic health record. If you ask physicians what the source is, the EHR comes up near the top of the list. I would actually argue, I can't believe I'm an apologist for EHRs, it's not their fault. They are simply executing the stupid payment model that, for primary care it's all about getting levels four and not level three visits. Being able to bill a 99214 code and all of these stupid check boxes you have to do in order to get that. So again, it's not the EMR's fault, they're just executing the payment model.
So, if you think the job of the EHR is actually to improve outcomes and not generate higher billing codes, then what are some principles behind it? So one is, we have to gather data about our patients from everywhere. If you think about it, trying to manage someone's hypertension with one number you're getting in your office every three months, it's completely asinine, right? Who cares about that number. They probably have white coat hypertension and that's not even their real number, right? We need to get a stream of numbers from them when they're at home doing their day-to-day right? So that's one, is get data in from their devices. By the way, get all their lab data. You can get the census data if they ever show up in an ER or a hospital, get the claims data from when they're filling their meds, right? To get a bunch of data.
Number two is, then generate insight from that data. Is there blood pressure going out of control? Did they fill that prescription you just did? And then the third, this is the most important, is then put those insights into the context of the relationship. It's a people and a data thing. And I think, that's the way we have to think about this. Continuous data flow. Generate insights. Don't give people a stream of data, give them the insight. And then, put that insight into the relationship to allow you to actually change outcome.

Dr. Daniel Kraft:
What advice would you have for other docs who want to help move that needle, whether it's to value-based care, transforming their practice? Because, often it's hard to get your head out of the EMR to do that.

Dr. Rushika Fernandopulle:
So first of all, I think we have a huge role to play in what I call bearing witness to how crappy the current system is. This is not working for our patients, this is not working for us, it's not working for the system. So, I think we, because we're watching it at ground level, and telling stories like the one I just did. In telling stories, bearing witness is a huge role we could play. Second is, I think we ourselves need to be part of the solution and be willing to change. People don't go into medicine because they're risk-takers, unlike you, right? But in general, people don't go to medicine because they're innovative risk-takers. They go into medicine because they want to take care of patients, first do no harm. There's a strong conservative streak in health care. I think that's all well and good, but it's not working, right?
So, we ourselves need to be willing to change and try new things. And then finally, I think in the end, we have vote with our feet, right? If our institutions are not willing or able to change, we need to have the courage to say, "We're going to vote with our feet." Whether it's going to a new job, going to a new practice, our patient, if I'm a patient, or my mom is a patient, taking her to somewhere else, that's the only way I think we will change the system. Doesn't want to work for having doctors make more money, making the hospital have more beds, getting the pharma company to sell more drugs, et cetera. So, we said, "We're going to work for our patients." Period at the end of that sentence. And the other stuff will work out. They'll be the side effects.
Number two is, we have this interesting principle, when in doubt do the more radical thing. So, we get faced with two paths. The obvious thing is, do the safest thing, but then you'll never know the more radical thing. If you do the more radical thing, if it doesn't work, you can always try the other one. So a good example is, we had built a lab interface early on where... So our patients, by the way, from the very beginning could see their own medical record. We thought, "Obviously they're in charge, they should see their own medical record." So, it's a question that we had built an interface with, I think it's Quest or Labcorp. And the lab values were coming in. The question is, "When should the patients see their lab values?" A, only after the doctor signs off on it, B, never, which is what most people do, C is after some delay, or D, right away. And people, of course, some you don't know, "Well, what if it's something," dah, dah, dah?
And I said the more radical thing, "This is their data last I checked. We should have them see it right away." And people are scared. I tell you what? "Let's build in a delay, but let's turn the delay off for now. And, let's just let it all go and let patients see it themselves. And if it doesn't work, we can just turn the delay on a two-day delay, right away, and then we'll be fine." Everyone was okay with that. By the way, we've never turned on the delay, right? Because, it turns out that patients are fine. If they see something they don't like, they'll call you, right? They'll reach out. And the thing we tell our docs is, "Your patient will see the results the second it comes in. So, if you want to talk to them about what that could be, you better have that conversation before you order the lab."

Dr. Daniel Kraft:
So, we're talking here in the fall of 2020. COVID is still very much with us. You, yourself, were on the Bigelow Awards at MGH doing inpatient medicine and how's COVID transformed your practice. And what has it catalyzed, and what do you think you're going to keep, hopefully post-COVID?

Dr. Rushika Fernandopulle:
I think COVID has shown that our payment model, this payment model of not doing fee-for-service thing by value is hugely important. What we and everyone else did right when COVID hit is realize we can't be seeing people in-person for everything. But, we spun down to about 8% of our visits being in-person, and the rest being by video or telephone. Number two is, I think, maybe more important. It allowed us to do the right thing, and the right thing was having a hybrid model. We kept every practice open. Are there a set of encounters which still, despite COVID, need to be done in-`person? Absolutely. If it doesn't need to be done in-person, by all means, we should do it by video. So we should figure out also, by the way, how to do it in video for people who are trouble accessing the internet or devices. So, we can figure that out.
There are a lot of people who swung as fast as they could back to all in-person. That's not the right thing to do, right? We need to use this as an opportunity to get the right care model. Individuals have some set of needs that are better done by a chat box, some that are better done by video, some that are better done in-person in office, some we have to go to their home. What we should be building is an omnichannel experience where we can meet all those needs for patients depending what they have, with the same relationship, same technology, same people, and tie them together, not be separate companies. And that's completely wrong.
So, only 11% of Americans say that they have heard one word from their primary care doctor during the whole epidemic of what they should do in COVID. I think our medical system has dramatically failed us in COVID. Again, lots of good people, good intentions, but the system has failed us. And by the way, we'll have another one like these. I think the thing that we've realized is, this is not the last time that even you and I in our career are going to see something like this. Hopefully we'll get through it, things will get better. There's another one of these things lurking around somewhere.

Dr. Daniel Kraft:
Yeah, my friend Larry Brilliant calls this the practice pandemic in some ways, because the next one could be twice as infectious with twice the mortality rate. And, I imagine you're starting to take in other data, not just from your practice but the sociome, or what the infection rates are, or where the local testing facilities are. Are you starting to blend modalities in for your providers and your patients?

Dr. Rushika Fernandopulle:
Absolutely. Again, so example, COVID rates in localities matter a ton about how you react to various things. So, we're pulling that in. We have not pulled in the socioeconomic data about our patients, but we're talking about it, because that's a really important thing we ought to know. So I think in general, this idea of being able to get data from everywhere and then, putting it into action is where we're going.

Dr. Daniel Kraft:
Switching gears a little bit, how would you reimagine medical education for any kind of provider, and what could current practitioners do to get themselves back up to speed in just, sort of learnings that you've had in general?

Dr. Rushika Fernandopulle:
So, I think it's a travesty that we are still teaching our trainees, whether they're medical students or residents, the old model of care, which is reactive, faxes, all of those things. So, I saw a couple of models. So one is, the fundamental job of a doctor in an Iora practice is not a little different than the current job of a doctor is very different, right? So no more if you think we will have better and better technology, better and better health coaches, et cetera. But, the job of the doctor is to see every patient and make every decision, right? Now, what I tell a doctor is, "You're still in charge. You're the most expensive person in the room. You are still accountable for the health of this population." So, the way we think about our job is, "You are population manager. You have X hundred patients, they're your problem."
Now you don't have to do everything, right? Some of it is, you need to oversee the data and you need to look at the data and figure out where to look. Some of it's you have to make the shared care plan for each patient. Some of it's you have to train and supervise the health coaches, right? So it's a data, it's a management, it's a training, it's a IT issue. And then, you need to get in and intervene on an individual patient when you need to get in and intervene on a patient. So again, great example, again going back to the hypertension model is, you put people on a plan about hypertension, you have them monitor it, check in with the health coach. You put them on escalating, start them with ACE inhibitor, and they're on a blocker. And, 80% of the time that program will work fine. You don't need to pay any attention unless they go off the deviation.
Now it turns out, as you know, maybe X percent, 2 or 5% of the people, they won't follow the program. And it turns out they don't have essential hypertension. They've got a coarct of the aorta, they've got a pheo, they've got some other strange zebra. And what we as doctors ought to be spending our time on is those people, not the 80% of people who've got essential hypertension and the stepped care model works just fine. So again, you got to put them on the track, have people do it, have a data system be able to flag quickly, "Hey, this guy is not quote, behaving normal. Now, my job as the doctor is stepping in and intervening."
So, it's a different job as a doctor. I don't think we're training people for this. So, I think we need to, A, start training people for the future. By the way, even teamwork. When we're in medical school, you don't need anyone who's not a doctor. You certainly don't work with physical therapists or whatever. You certainly don't have a lot of insight into data, or analytics, or change management, or any of those things. So, I think we need a whole separate set of things we're teaching people.

Dr. Daniel Kraft:
So, let's have fun. Let's leap forward to, I don't know, we think we're in the future 2020. It seems like we're still back to the future, but let's say health care 2030, arguably we're going to all have $10 genomes, and Tableau, and sociome all integrated in. How are you building your practice for that and what might other practitioners do to future-proof things a bit?

Dr. Rushika Fernandopulle:
I think the key thing that'll change between now and even 10 years from now, well within our career is real personalized medicine. I know there's a lot of talk about that. I think it's happening. You know this, that it's happening. We do a ton of medicine trial and error at the moment, right? So, I think I need to give you a drug for X, I want to try, one doesn't work, I'll try another, try another. We make recommendations based on 51% of people in a trial having benefit and we give it to all 100%, it's ridiculous. Come up with an individualized plan and then, treat each patient as a experiment N of one, right? So, let's see if it's working, if not, then let's change it, et cetera. That's the mental model we all need to have.

Dr. Daniel Kraft:
So, given the influx of new forms of data, are you able to architect your system to take some of those in whether it's the microbiome, or the behaviorome, or the internet of medical things? Have you learned if you're treating a millennial versus a baby boomer, how to mix that into the equation so you're really providing this holistic element that then can translate to another doctor or Iora clinic across the country?

Dr. Rushika Fernandopulle:
Yeah. And so, one thing I think we're really bad at in health care is segmenting the population. So in some way, I'm saying something very heretical. I actually think that trying to build a typical primary care practice which does all things for all people, is an unwinnable game. No restaurant in the world says, "I'm going to build a restaurant, I'll cook whatever food you want. I'll cook Italian, Chinese, and Greek." What we need to do is segment. So, we of Iora practices are focused on seniors. We may actually further segment that into young seniors and old seniors, right? The ones who are not very tech-savvy in the nursing home and then, 65 to 75-year-olds who, you and I are not that far from that unfortunately, who are still working and active, and whatever. So point one is, I think the way to do this, because you can't do everything for everyone, is to segment into a reasonable number.
Now again, the backend infrastructure, all the data, the analytics, actually the hard part, needs to be scaled like hell. But the end unit that faces the customer, maybe ought to be targeted. So again, a simple thing. When we open senior practices, we can close them at 6:00 PM. No one's going to come to us at 8:00, they're the early bird special. Whereas, we open practices for younger people, you're silly to be opening them at 9:00 AM. No one's awake, right? You should be opening till 10:00 PM. So I think, different hours, different vibe, different locations, different staffing you have.

Dr. Daniel Kraft:
One of the perceptions, you talk about having an older population, is that they can't use technology. Maybe, it's that connected blood pressure cuff or the app to track their meds, and issues of health equity, whether you have internet access or smartphone. Have you found ways to bridge that? Will you loan someone a smart device?

Dr. Rushika Fernandopulle:
Yeah, absolutely. So particularly given COVID, we think it's really important that we be able to digitally enable encounters with our patients as well as see them in-person. So, we have a number of things we do. So one is, we do have a tablet loaner program where we actually loan or give people a tablet, which is already linked to the internet. We have a program where we actually show up at their house with a tablet and we help them. We do some Saturday hours so their kids can come over and help them. So, there's a variety of things.
Again, why are we able to do this? Because we have a payment model where if we keep people out of the ER or the hospital, we get to keep that money. So, it's a really simple math, like a hundred dollar Android tablet versus them going to the ER for a thousand dollars, "Hmm, what should I do?" Of course, I should give them the tablet, right? So, it just makes it much easier when we can be fungible about these sorts of resources.

Dr. Daniel Kraft:
Any other lessons in helping individuals become more autonomous, and partners in their care?

Dr. Rushika Fernandopulle:
We should treat patients like apprentices. So, how does that work? First, we do what they watch, then they do what we watch. Eventually, we sort of step back and let them do it and we're the safety net. We just keep an eye on it. And, only if it's going off the rails do we get involved. The goal has got to be for us to give themself self-efficacy for them to manage their health because they will always be better at it than we are. Not because it's cheaper, but because it's better.

Dr. Daniel Kraft:
Yeah. The old Marcus Welby model of, go to the doc, they'll take care of it is certainly shifting and it's a big part of it. Yeah, I step on my scale and if I'm up, then I know what to do. It's small data, too.

Dr. Rushika Fernandopulle:
Absolutely, it's small data. It's not big data, it's small data. Because the problem is, we can do insights on big populations, that's fine, but the best insight is from you. Again, it's simple. They're diabetics. People do it for years. I know if I eat an ice cream sandwich exactly how many units of insulin I need. It's by the way, different than someone else's needs. But I know myself, right? This is how my body works.

Dr. Daniel Kraft:
Yeah, speaking of that, I just got a continuous glucose monitor for fun. I'm not diabetic, but it's really interesting to see the results, and your response to certain foods. And, you learn that. You don't need to be wearing the patch after that. You've got your sort of food print developed.

Dr. Rushika Fernandopulle:
Yep, now you know. Yep.

Dr. Daniel Kraft:
So, speaking directly to fellow health care providers, anything you want to add that we haven't covered or lessons learned?

Dr. Rushika Fernandopulle:
So, I think it's really easy to be scared of the future. Things are changing rapidly. COVID has accelerated these things. I actually think the future is really exciting. I think that this new technology, sort of the foment around COVID, the foment around new payment models, the existence of people like us at Iora, new delivery models, are actually really good, or could be really good. And I think, done right, can really enable us as docs, as other health care people to do what we train to do. And to actually take care of patients and not get caught up in the faxes, and the codes, and all of that. So, I think we all have a choice. We can kick and scream... The present isn't working, right? We can kick and scream and resist change, or we can be part of the future, and that could be a much better path.

Dr. Daniel Kraft:
Well said. Well, thanks Rushika for everything you and your Iora team are doing. You're certainly not waiting for the future to arrive, but you're building it. And are helping to catalyze a lot of this new thinking and models and mindsets, which are really going to shift health care in the US and around the planet. So, thanks for joining us on Healthy Conversations.

Dr. Rushika Fernandopulle:
Very welcome.

Dr. Daniel Kraft:
Thanks for listening to Healthy Conversations, the podcast. It's our mission to reveal the front lines of the health care profession and to educate everyone about the challenges and opportunities in this new landscape of health care.