An organic effort to reboot healthcare

For the better part of a decade, I practiced inpatient hospital medicine at a large academic center (the name isn’t important, but it rhymes with Afghanistan … ford).

I used to play a game with the med students and housestaff: Let’s estimate how many of our inpatients actually didn’t need hospitalization, had they simply received effective outpatient preventative care. Over the years, our totals were almost never less than 50%.

For my fellow math-challenged Americans: that’s ONE HALF! Clearly, if there were actually were any incentives to prevent disease, they sure as heck weren’t working.

In a country whose care pyramid is upside down — more specialists than primary care docs, really? — we’re squandering our physical, emotional, and economic health while spending more per capita than anyone else. Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)

Worse still, the oppressive weight of our non-system’s dysfunction falls disproportionately on the shoulders of our primary care providers — the very instruments of our potential salvation. To them, there’s little solace (and plenty of administrative intrusion) in the top-down reform efforts of accountable care organizations and “certified” patient-centered medical homes.

But what about a bottom-up, more organic effort to reboot healthcare? A focus on restoring the primacy of human relationships to medicine, empowering patients and providers alike to become potent, positive levers on a 2.8 trillion dollar economy? What if we could spend twice as much on effective, preventative primary care and still pull off a net savings in overall costs, improvements in quality, and increased patient satisfaction?

What if George Lucas had just quit after the original Star Wars series? Wouldn’t the world have been better without Jar Jar Binks?

While the latter question is truly speculative, the former ones aren’t. We’re trying to answer them in Las Vegas (hey now, I’m being serious) at Turntable Health, where we’ve partnered with Dr. Rushika Fernandopulle and Cambridge, MA based Iora Health.

We aim to get primary care right by doing the following:

1. Fix incentives. Fee-for-service reimbursement structures encourage providers to do things TO people, instead of purely FOR them. My father, a dedicated primary care doc, used to encourage me to specialize because “there’s $500 in everyone’s colon. Go in with a scope and retrieve it!” This ridiculous incentive system has no place in primary care where it rewards episodic rushed sick-care visits (with often unneeded referrals and testing).

By banishing fee-for-service insurance in favor of a flat-fee membership model, we incentivize strong relationship building and longitudinal population management. Ditching insurance billing means up to 20% less overhead and 2434.76% less aggravation. We eliminate copays and barriers to care, encourage use of convenient methods of patient engagement (phone, video, email, group visits, yoga classes), and free providers to focus on outcomes, cost, and patient satisfaction for their entire panel.

Unlike “concierge” models reserved for the wealthy, our services are offered with wrap-around insurance plans by the not-for-profit Nevada Health CO-OP and are eligible for federal subsidies on the state health exchange. That’s a model that puts the “care” in Obamacare, folks.

2. Shift the culture. There’s no “I” in “team” and but there’s a “we” in “well.” Apart from making the lamest bumper sticker ever, this sentiment is valid and should drive a new culture of care away from cowboy autocracy and towards non-hierarchical, collaborative teams where everyone practices at the top of their training. We have doctors working with nurses and licensed clinical social workers, but the unique twist comes with our health coaches.

Drawn from the very communities they serve, they’re hired for empathy and emotional intelligence and trained for the skills needed to motivate and support patients in setting and attaining goals. Each morning our full care team “huddles” to discuss all the patients who are to be seen that day, and all the patients who AREN’T but who merit outreach to keep them out of trouble.

There’s teaching, learning, and feedback. It’s goose-bump inducing stuff, folks, and should inspire our young physicians-in-training.

3. Make tech the glue. Most electronic health records are glorified insurance billing platforms with some patient care stuff thrown on top. So our partners Iora Health had to build one from scratch. Issue-based, with seamless assignment of tasks to a members of the collaborative team, it facilitates effective preventative population management while stripping away boilerplate nonsense designed to please no one but a bean counter at an insurance company.

Patients can read (and soon write in) their record because, well, it’s THEIRS, isn’t it? Tech should create connections, not barriers.

The results of all this? Significant improvements in hypertension, diabetes, and depression control. Evangelical patients whose satisfaction scores skirt the 90% range. Providers who love coming to work each day.

And an overall reduction in costs DESPITE the higher upfront spend on primary care. It’s the Wikipedia definition of “no brainer.”

Which is why academic medical centers should be exposing their trainees to what we and others, like ChenMed and Qliance, are doing to innovate in primary care. They should implement similar clinical models for their own institutions, models that encourage collaboration and break down hierarchical, autocratic structures.

Because what’s better for patients is also better for students, who know full well that they are entering a horribly dysfunctional system. We’ve seen how inspired they become when they see primary care at its best, when doctors are freed to simply do the right thing for patients. They recognize that this is what the future of healthcare needs to look like.

And it could look like this, if academic medical centers step up and become part of the solution.

Zubin Damania is CEO and founder, Turntable Health. He can be reached on ZDoggMD and on Twitter @ZDoggMD. This article originally appeared in AAMC Reporter.

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  • buzzkillerjsmith

    Tech the glue. Lost me right there.

    Lots of words, not much meaning. Move along, Johnny. Nothing to see here.

    • Dr. Drake Ramoray

      He lost me at point 1 abolishing fee for service.

    • ZDoggMD

      I suggest you drop by our clinic next time you’re in Vegas. Then you can see what there is to see, and forget the semantics ;-)

  • Margalit Gur-Arie

    Okay, at the risk of bringing the house down on my head, I would like to understand how these chains of cash practices are intrinsically different than traditional corporate medicine.
    Seeing how the largest chain is owned by Procter & Gamble, and others are funded by venture and private capital and management companies that also own insurance companies (of the BCBS type), and seeing how most of these cash chains are contracted with employers, I don’t quite get the “direct” aspect here. Isn’t there the same conflict of interest present here as in any for-profit health system owned practice?
    I can see how it would be very different to have a doctor that just hangs his/her own shingle out there and takes cash the old fashioned way…..

    • Dr. Drake Ramoray

      Its the same, and the ones you cite also push for all this pay for performance, integrated EMR, health coaches, federal subsidies etc. The era of the free standing practicing physicians is over, at least in terms of seeing patients who rely on insurance. Nobody can use any of these PCMH/ACO models (which don’t even save money) and meet meaningful use without federal subsidies and/or support of corp med.

      The last gasp of personalized medicine will be concierge medicine and a few who will strike out as individuals for direct pay who think it can be done at a reasonable price. I think direct pay can work and be cheaper for niche care (like thyroid only that I am exploring) but I don’t see it being effective for complicated patients with multiple medical problems, especially those without money. They will flounder in our corp med PCMH/ACO system for the foreseeable future. Anything is better than the model to which we are headed. There is a reason why my interest in practicing medicine oversees continues to increase.

      • Patient Kit

        Floundering!!! No wonder this mermaid (me) finds navigating our healthcare system so exhausting. I hate floundering. I much prefer swimming fast and free. Patients need a Plan B too. Mine: Opt out of the US healthcare system completely and go die on a beach in Mexico, young but happy.

    • Mike Henderson

      ” I don’t quite get the “direct” aspect here. Isn’t there the same conflict of interest present here as in any for-profit health system owned practice?”

      Is your question about direct pay in general or chains of direct pay clinics versus a typical for profit clinic?

      Is there a reimbursement model for physicians to treat healthy/wealthy patients equally as they do chronically ill/poor patients and not put profits ahead of the patients health as in a typical for-profit practice? I am unaware of such a model. Do direct pay/cash practices eliminate the conflict of interest that typical for-profit clinics have? Overall, no.

      Here is my attempt to explain the differences of direct pay in general versus a typical for-profit clinic. In a direct pay clinic, you get paid whether the patient sees you or not and if they are healthy or ill. In order to handle more patients though, and therefore increase income, you have to keep patients healthy. In typical clinics, keeping patients healthy is bad for profit.

      For example, lets say you are in a direct pay clinic and had the freedom to do whatever it took to keep your patients healthy, it would be in your interest to do so. When you are evaluating patients, you can respond to what that individual patient needs, not just what you get paid for. In a typical clinic, you are so limited by time and the need to generate revenue, you are driven to do only what you get paid for – which would not be to keep them healthy. The current system only pays when people are ill.

      In a direct pay clinic, it is in my interest to take the patients phone call if they think they are having a mild adverse reaction to a medication, or it isn’t working well enough. They don’t have to set aside half a day in their busy schedule and come in and see me. If they started lisinopril and had a cough, the medication could be switched more quickly and thus they would be compliant. If they were monitoring their blood pressure at home, assuming the readings were verified accurate, the dosage could be adjusted much more frequently. Direct pay lets physicians meet the needs of their patient much more freely, instead of tying all medical decisions to an office visit. How about labs that show minor abnormalities? They want to know about the results, but in a typical clinic, they again have to be seen in the exam room. It is more efficient to just talk on the phone for 10 minutes so they understand what the numbers mean. In a typical clinic, physicians can’t afford to spend 10″ talking on the phone about this or that, requiring a visit to the clinic – this adds more work for the receptionist, MA, yourself and the back office staff.

      In summary, in my current opinion, direct pay at least allows for the option for physicians to do what is really in the best interest of the patient and keep them healthy. Typical, insurance governed practices drive physicians to provide care only in the exam room and only rewards physicians for when patients are ill. Think about this: what would happen to a physician, in a typical clinic run by profit driven administrators, who reduced patient visits by 10% because they were more effective at keeping their patients healthy and out of the clinic? What would happen to that physician in a direct pay clinic run by profit driven administrators….?

      • Margalit Gur-Arie

        So isn’t this pretty much like capitation?

        I usually understood “direct” to mean direct payment from the patient to the doctor, hence the patient is the client. But if the payment flows from an employer, on behalf of a group of patients, to a corporate entity, which then pays the doctor a salary, how is this a “direct” primary care relationship?

        Maybe I’m getting caught in semantics, but doesn’t this chain of transactions defeat the purpose?

        • Mike Henderson

          The main benefit to posting on these forums is sharpening of my thinking, so much thanks for the question. There isn’t any point in promoting direct pay if it is capitation, renamed. Semantics are therefore important.

          To answer your last question first, having more middlemen/employers could defeat the purpose, but I don’t have any experience with chains dealing with employers. It would seem better than dealing with insurers, though.

          Capitation was before my time, so I don’t quite know the details of how it worked. What is capitation? It is an agreement between an insurance company and a provider to care for a defined group of patients for a set amount of money over a set period of time to confer risk to the provider. It’s a healthcare financing model (feel free to correct me if wrong) with the primary objective to control and lower costs. As a physician, my primary objective is to provide the best outcome for my patients. What happens in a capitated model when there is a question about a diagnostic workup or therapy? Do we prioritize cost control (and avoid services based purely on cost) or best patient outcomes?

          Some will argue that providing the best patient outcome will result in cost savings – no it won’t. For example, preventive medicine as a whole, going forward in time, doesn’t save money. You can always take a specific patient who had a bad outcome that could have been prevented and say that preventive medicine would have saved money in that specific case. But going forward in time not knowing who will have a bad outcome, you have to screen and treat the whole population, which isn’t cheap. It costs $50k for every year of life saved by screening for breast cancer. In other words, dying is $50k less expensive. 1000 women need to be screened for 10 years to save one life. That involves a lot of mammograms, diagnostic mammograms, ultrasounds, biopsies and for those diagnosed with cancer, surgery, drugs, radiation and chemo. In the definition of preventive medicine, there isn’t anything about a guarantee of saving money.

          In the direct care model, at least in my mind, the priority is to provide the best care and then figure out how much does that cost. This is the reverse process of capitation, which avoids care simply based on its up front costs.

          My personal calculations years ago was that it would cost me $40 minimum per month, per patient and go up to around $90 for really complicated patients. How much do we get from capitation? From what I read in our local paper, $20/month for Medicaid patients. Second, direct pay avoids the insurers and their overhead bloating rules. Since I don’t contract with them, I don’t have to worry about prior authorizations or constructing redundant notes high school graduates can understand. The insurers can explain to the patient why they are refusing to pay for something, which leads to third, it uncovers the manipulation of patient care that insurers exert via physicians – a denial of payment has to come directly from the insurance company to the patient. Insurers want to put up roadblocks so that physicians will just automatically avoid considering certain options – the patient will never know something else could have been done and the insurance company avoids looking like the bad guy, but the physician is the one exposed to the risk if something goes wrong. Physicians, no doubt in my mind, avoid to some degree offering options involving prior authorizations. Insurers absolutely want to heavily influence our medical decisions.

          Basically, who pays me is who I work for. In capitation, I am still paid by the insurance company.

          • Margalit Gur-Arie

            I agree with you on the benefit of forums…

            I am not questioning the model where I pay you $40 or $90 or whatever you calculate to be needed for you to be able to practice good medicine and make a good living. I do understand the directness of it, and I think it’s a great model.

            My understanding gets fuzzy, when some business is asking me to pay the business $80 and they assign me a doctor to keep me healthy. First, I have no idea how keeping me healthy is the business of medicine (and not of my grandma for example). Second, if the doctor is a salaried employee of that business, then he works for whoever pays him, and now I have to question the motives of his employer which is some far away management team with investors and shareholders and dreams of going public, or selling out for a huge profit, as all investor backed startups dream of. Is it better than the old insurance company? Maybe, but I don’t know that….

            If the management company is paid by my employer, then the management company works for my employer, and the doctor works for the management company, and I am really not a factor in any of their decisions. Now I am supposed to trust that my employer is looking out for my best interests, in addition to trusting that the doctor’s employer is also catering to my interests. There is too much indirection here for my taste.

            For me “direct” pay means that I give you, the doctor, money or chickens, once a month or every time I see you or both, and you care for me if I get sick.
            Anything else is just another way of introducing middlemen into our relationship. Maybe nicer middlemen, and I doubt it, but still a series of folks helping themselves to a portion of the money we exchange, for no good reason.

          • Mike Henderson

            Your perspective is very helpful. That’s what I was looking for.

  • Dr. Drake Ramoray

    I will ignore your babble about tech (and satisfaction scores for that matter.).

    I will however address point number 1. Eliminating fee for service (something that is present in almost every other counry that has single payer) and moving to a pay for performance payment method encourages doctors to take care of healty well patients and discourages doctors from taking care of sick patients. This punishes patients in lower socioeconomic brackets with regards to access to care and punishes providers who continue to work with under served, poor patients. You wish to compare the suburban executive with metformin controlled diabetes to my rural practice with some patients with a sixth grade education, multiple diabetic comorbidities on insulin, and transportation issues.

    Pay for performance is lose lose for patients and providers. If you don’t believe this doc practicing in the rural diabetes stroke belt in the South perhaps you will listen to the New York Times.

    • ZDoggMD

      Thanks for the thoughtful response Dr. Drake. To clarify a few points here: we do NOT do pay for performance in any way shape or form. Full stop. Our doctors are salaried and simply do what they feel is best for patient care. Second, via our partnership with Nevada Health CO-OP, we are able to see patients who are between 100%-400% of federal poverty, as they receive subsidies on the exchanges for the insurance plans that include us (for free, with no copays). Many of these patients have multiple comorbidities and haven’t seen a doc in years, and are profoundly grateful for this access. Our clinic is located in Downtown Las Vegas, the most economically depressed low income area in the entire city, and we are proud to serve folks who would never in a million years be able to afford “concierge” medicine.

      Re: federally subsidized health coaches, we don’t have such a thing. We have our own paid health coaches whom we train ourselves.

      Re: Tech as the “glue”, it is, when clinicians build it around their workflow, rather than have to build their workflow around the tech.

      • Dr. Drake Ramoray

        Interesting. Thanks for the clarification. It sounds like you have a pretty good thing going. I have spoken with a couple docs who have been in salaried positions before and they all commented that there were always a few ba apples that wouldn’t see very many patients and/or didn’t have motivation to see more. There are of course bad apples in any set up. Anything is better than pay for performance

      • SteveCaley

        Good dea – tech adapting to provider needs. Describe, please. Never seen so far.

        • ZDoggMD

          The engineers get twice monthly updates from the clinicians as to what the evolving needs of the clinical practice are. Using Agile development, they are able to implement many of the changes quickly, resulting in software built around clinical workflows, rather than the other way around.

  • SteveCaley

    “Shift the culture. There’s no “I” in “team” and but
    there’s a “we” in “well.” Apart from making the lamest bumper sticker
    ever, this sentiment is valid and should drive a new culture of care
    away from cowboy autocracy and towards non-hierarchical, collaborative
    teams where everyone practices at the top of their training.”
    This often is brought out in management meetings; it’s a sign that corporate’s been on the phone with fresh buzzwords. Cowboy Autocracy’s been gone since Gene Autry hit the trail. We should stop Wednesday Afternoon Golf, for all the relevance of that suggestion. Recitations of ‘what we should’ is easy. HOW to effect cultural realignment, other than some hard coercion?

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