by Marty Makary
In Phoenix, I learned more about how Iora works. They are hired by an employer or insurance company to take care of a population of people, such as a group of 10,000 seniors. Each person in that population is assigned an Iora doctor and an Iora health coach.
The coach joins each patient for their doctor appointments. After the doctor leaves, the coach stays with the patient to go over next steps. Health coaches call patients to check in with them and help coordinate the other specialist doctors the patient may need to see. They get to know their patient’s situation well and facilitate good communication between doctors. Iora doctors and nurses are free to take care of people in whatever way they see fit, ranging from home visits, to giving a ride to see a specialist, to enrolling their patients in one of their classes. They pride themselves in spending a lot of time with patients so they can understand the individual’s goals, struggles, and barriers. The Iora health coaches make everyone’s job a lot easier.
Sarah Cabou told me about her previous job before coming to Iora. She was the nurse supervisor of an outpatient bone marrow transplant center where patients would routinely fall through the cracks. While I personally don’t do that procedure, I know that bone marrow transplants are a care coordination challenge—perhaps even the hardest care coordination challenge in medicine. Here’s why: Patients are hit hard with chemo for weeks or months until their bone marrow counts hit an all-time low, then they are given a bone marrow transplant, perfectly timed and perfectly matched with a donor. To be cleared for the transplant, these patients require a slew of consults with nephrologists, cardiologists, infectious disease doctors, and other specialists, due to the toxic effects of the chemo. Cabou told me that she often watched patients have their cancer recur simply because the coordination was too much for any one patient to manage.
She also previously worked with Medicaid patients. She routinely saw patients missing appointments because of confusion, complicated insurance procedures, not having a ride, being in the hospital at the time of their appointment, or avoiding care because they never wanted it in the first place. She saw enormous waste in the system and felt compelled to be a part of something better. The final straw was when she watched a doctor seeing patients for 15-minute visits with an egg timer on his desk. “We’ll talk until the timer goes off,” Cabou recalled his telling patients. “Fee-for-service medicine values quantity, not quality,” she said.
She showed me around the clinic, which included a community room for cooking classes and game nights for lonely seniors. We walked to a modern conference room where every member of the ten-person staff had set up a small workstation. The open office design looked more like a tech start-up than a clinic. Impromptu conversations about patients filled the room.
I had seen the whole operation when it hit me: “Where is the billing office? Where is the business area where insurance claims are processed?”
The clinic staff who heard my question began to laugh. They had no billing people. The clinic is paid a lump sum annually to care for a population of patients, so there isn’t a lot of paper to push, or time to spend cajoling anyone to pay up. Gosh, I thought, back in Baltimore, my office staff and nurse practitioner spend hours on the phone with insurance companies. Iora spends almost no time on that stuff.
“We don’t need a back room for billing, so we use it for health activities,” Cabou explained. The extra space allowed them to hold sessions on yoga or fitness or how to manage your lifestyle if you have a chronic disease.
I couldn’t believe what I was seeing. A true health center.
It was now 8 A.M., time for the daily staff huddle in the open workroom. Around the table with the big screens on the walls, the room was set up to talk about each patient who had an appointment that day while reviewing their data on the screens. Present at the huddle was the entire clinic staff: health coaches, nurse practitioners, a doctor, and two receptionists who handled the phone lines. A different team member leads the huddle each day, instead of just having a doctor do it. Sara said it was designed that way to promote a more egalitarian culture, so everyone feels free to speak up about any patient. On the clinic schedule, most patients were allotted an hour. Evidently that’s common. Iora staff want to ensure they have plenty of time with each patient.
For the next hour, I watched the Iora team perform like an orchestra. Almost everyone in the room knew every patient being discussed and had something to contribute. When someone announced good news about a patient, everyone cheered. When a difficult case was discussed, they put their heads together and came up with a creative way to handle it. Everyone seemed invested. As they ran through the list of patients, I heard people in the group say things like “I’ll give her a call to remind her,” “I’ll go visit her to make sure she’s doing okay,” “I’ll call her hematologist to make sure we’re on the same page,” or “I’ll see how she’s doing since we stopped her medication.”
The group also reviewed outstanding issues from patients they saw the day before. Sarah Cabou would assign follow-up tasks to health coaches to close the loop on next steps. The group took time to discuss patients in their practice who had been admitted to a hospital or gone to an ER. When they learned of a patient’s admission, they called the hospital doctor to provide the patient’s medical and social background. While I was there, a patient of theirs showed up at Mayo Scottsdale with a high INR level—a test indicating the blood is too thin from blood-thinning medication. A health coach quickly followed up with the patient to review how to properly take their blood-thinning meds. The receptionists had extensive insight on each patient coming in. They routinely called each patient to remind them of their appointment and to make sure they had a ride. If they didn’t have a ride, they offered to send a car to pick them up. At one point during the huddle, a receptionist told the group that a patient was apprehensive, and at risk of not showing up. For another patient, a receptionist mentioned she thought a patient might be trying to game the system.
Including front office staff on morning rounds was brilliant. I learn a lot about my patients from my office manager, Trish McGinty. She knows which patients are doing well, which are leaning against having surgery, and which are also coping with other social problems. The inside information that Trish gleans from talking to my patients is invaluable. Once she even warned me about a patient’s angry husband. Even though the woman was cheerful and thankful when I saw her in clinic, I was grateful for the heads-up!
As patients began to come in that morning, each one was ushered into a spacious examination room with a round table and three chairs: one for the doctor, one for the patient, and one for the patient’s health coach. Extra chairs were nearby for family or friends. The health coach sat in on every doctor appointment, took notes, and followed up with the patient to coach them toward the goals the doctor recommended. As patients were being seen in the examination rooms, the staff conference room turned into a busy command center; each staff person sat at the table like an open office and tossed questions or concerns about patients to Sarah Cabou, who would make decisions or delegate them to the doctor.
Sitting in the conference room for a few hours, I watched health coaches pop in and give detailed information on patients to the doctor and clinic supervisor. They would work through problems, make calls, and coordinate care.
“What I love about this job is that everything is at my disposal to help patients,” one of the clinicians told me. “I can bring someone in with a car service, set up a video chat, or send a health coach to their house.”
At one point, a phlebotomist (a health care professional trained to draw blood) walked in and told Cabou, “This patient’s cardiologist ordered a lab test that we already did two weeks ago. Do we really need to repeat it?” Instead of sticking the patient with a needle again, the team submitted a copy of the prior results to the cardiologist, who then agreed not to repeat the test.
One patient was a 73-year-old bus driver for kids with disabilities. He kept getting readmitted
to the hospital for congestive heart failure (CHF), a condition treated with a medication called a diuretic, which addresses fluid buildup by making a person urinate. The Iora team got alerted about his hospitalization for CHF-related fluid overload at the huddle, and someone asked, “Why is this patient not taking his meds and why is he getting readmitted so frequently?” They probed further and learned that he did not want to urinate often because he feared leaving the kids alone on his bus. The patient insisted he’d rather suffer heart failure than abandon the kids even for one minute.
After discussing his case, the Iora team compromised by switching the patient to a more moderate medication. It would treat his CHF without causing such frequent urination. They were also able to change his medication schedule so he didn’t have to make so many bathroom stops when he was with the kids. It worked. The patient was able to do what he loved doing—driving kids—while getting a reasonable treatment for his heart disease and avoiding frequent hospitalizations. Sarah Cabou attributed the success to their strong rapport with the patient, which allowed them to understand his unique situation.
At another point in the day, there was an elderly new patient who had been feeling light-headed. Without doing a litany of brain MRIs and other tests, the doctor, Sara Peña, realized he was on medication that was lowering his blood pressure. After spending a lot of time with the patient, she learned he had a lifetime history of high blood pressure. His body had adjusted to that high pressure to supply blood to his brain and other organs. Given his history, Dr. Peña adjusted his medications so that his blood pressure would be on the high-normal side rather than the low-normal side. His light-headedness went away. No pricey brain scans were necessary.
“I think there is so much overtreatment because doctors don’t have time to explore what patients are capable of doing,” Dr. Peña explained. “What they want to do, and what they feel is important.”
Patients love the care they receive from Iora. Most say they would highly recommend the clinic to a friend, according to the company’s net promoter score, which gauges customer satisfaction.3 Iora’s score is over 90, meaning that 90% of customers would recommend Iora to a friend. A score that high is rare in health care. By comparison, United Airlines has a net promoter score of 10, and most primary care doctors have net promoter scores around 30.
The patients may love Iora partly because the culture is so friendly. Increasingly, when I talk to patients I meet in my clinic or on the road, I’m convinced we are living in an age of rampant loneliness. It’s reached endemic levels. I see more patients coming to appointments alone than I ever have in my career. When I ask who will be with them during surgery, or whom I should call afterward to confirm they are okay, they often answer “No one.” I see it in the gym, too. Back in college, we would all socialize and talk between lifting weights. Now everyone wears earphones and walks around like a zombie. Loneliness is a leading public health problem. At Iora, they hold game nights and cooking classes designed to provide community. “We see people make friends,” Cabou told me. “We need that, because many of our seniors are lonely.”
After my visit to the Iora Health clinic in Phoenix, I asked Dr. Fernandopulle how he created such a great organizational culture.
“We hire for empathy and teach for skill,” he said. Iora’s hiring process begins with running applicants through something akin to speed dating, to identify those that have the needed people skills. “Unfortunately, so much of what is done in health care is transactional,” said Fernandopulle. “But transactions don’t treat people, relationships do.” As a doctor, I found Iora’s teamwork approach to their patients refreshing. Team-based care frees up doctors to be more efficient. As a result, they care for more patients. At Iora, nurses and health coaches do as much as they can, including following up on treatment plans set by the doctor. As a busy doc myself, I’m convinced there are so many aspects of a physician’s job that can be done by a highly motivated helper. With the right attitude, a reliable assistant can make all the difference in the world, regardless of their level of formal schooling. For example, I could train a highly dedicated college graduate to manage medication compliance, do nutrition teaching, and follow up on tasks. This kind of trained help allows doctors to concentrate on the critical decision making at the heart of the practice of medicine. It’s no surprise that Iora staff have high rates of job satisfaction at a time when about a third of doctors nationwide are burning out. The enthusiasm at Iora was palpable.
Sara Peña said she loved working with colleagues who believe in medicine that is patient-centered rather than business-centered. She also said she loved having resources to help—from the coaches to the rides and video chats. She enjoyed the autonomy to do whatever she believed was best for the patient. You may be surprised by how many people who work in medicine want to be a part of something this holistic. Iora draws these types of health care providers, or clinicians, who believe in treating the root causes of medical conditions and are keenly aware of the risks of overtreatment.
At the same time, it’s important to note that Iora staff are not playing in an amusement park without accountability. Their performance is measured using standard metrics of health care quality and utilization—such as how many people in their population go to the ER or are hospitalized, among other outcomes. They have a lot of data on the “frequent flyer” patients in their practice—that is, patients who keep bouncing back to the hospital.
Iora is not cherry-picking, taking care of only healthy patients. Most of their patients are on Medicare. Two thirds of Medicare beneficiaries have three or more chronic conditions, 27% report fair or poor health, and 31% have cognitive or mental impairment.4 These patients are extremely expensive to the health care system. Moreover, they are particularly vulnerable to health complications.
Dr. Peña pointed out that while their team cares for “a population,” they are held to metrics for the entire group. They do outreach to patients who have never come to clinic or who miss appointments. The receptionists call them and report back on what’s keeping them from getting medical care. Every staff member in the clinic could quote to me one of Dr. Fernandopulle’s goals: “We need to talk about the patients that don’t see us as much as we talk about the patients that do see us.”
Meeting with the clinic’s staff, I learned how Iora’s model helps overcome barriers to good health. After all, do we really think doctors can manage overlapping chronic diseases with a couple of 15-minute visits per year? The current health care system is like a game of whack-a-mole. Iora shows that good health care is best achieved by a team of doctors and nondoctors who can dive deep into their patients’ work, social, eating, sleeping, stress, and exercise life. By using a relationship-based approach, Iora is getting ahead of the underlying drivers of chronic conditions. In addition to restoring humanity to medicine, Iora is lowering health care costs.
After at least three months of engagement with an Iora care team, the number of patients whose hypertension was controlled increased from 59% to 74%. Results from a cohort of 1,176 Iora Medicare enrollees over an 18-month period showed hospital admissions cut in half and emergency department visits reduced by 20%. The total medical spending by the insurer declined 12%. Since that study, Iora has now reduced health care spending for the populations they care for by 15%. Imagine what a 15% reduction in Medicare’s roughly $1 trillion budget would mean for the country. “The goal is not to save money, but if you do the right thing, it does save money,” Fernandopulle told me.
The Iora model offers a novel model of delivering patient-centered health care that actually saves money. An investment in relationship-based, holistic medical care has paid off with bigger savings in the form of patients taking fewer medications, and fewer trips to the hospital. Given the high cost of an ER visit or hospitalization, it’s no surprise that well-designed care has a strong value proposition. The model works, and other primary care groups like ChenMed, a Florida-based group, and Oak Street Health, an Illinois-based
group, are having great success using it as well. ChenMed not only delivers holistic primary care, but they also take on the financial responsibility for each patient’s downstream medical costs, whatever they might be. Accordingly, ChenMed refers their patients to highly screened specialists who believe strongly in the appropriateness of care. ChenMed’s success is a testament that great medical care is often less costly medical care. Together these companies are disrupting health care.
My optimism about the future of health care stems from the many committed, smart people, like Iora founder Fernandopulle, with big ideas on how to challenge the status quo to restore medicine to its sacred mission. Iora and other disrupters that are laser-focused on putting the patients at the center of their efforts are becoming the Tesla of health care.
CHAPTER 12
Disruption
My friend Dina came to town to visit me for a weekend. During her stay, Dina began to feel sick. I took her to the local emergency room, and in doing so, I saw firsthand what patients go through.
“You are out-of-network,” barked the receptionist. She acted as if Dina was a junior high student caught stealing chocolate milk.
The law is clear in the United States. Hospitals are required to treat patients during an emergency, regardless of insurance status.1 I stepped into the conversation to talk to the receptionist. “Is this hospital still going to take care of her as the law requires?” I asked.
The receptionist gave me a look of disgust. Then she prepared us for billing Armageddon. “Your insurance may not pay, in which case you will be responsible for the bill,” she warned.