Rebooting Primary Care From the Bottom Up

Rebooting Primary Care From the Bottom Up

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Zubin DamaniaFor 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.

ZDogg MD aka Zubin Damania, MD (@ZDoggMD) is CEO and founder of Turntable Health. An earlier version of this post appeared in the March 2014 edition of the AAMC Reporter.

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53 Comments on "Rebooting Primary Care From the Bottom Up"


Guest
Apr 16, 2014

What a refreshing post!
I like this part a lot…
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.)

Guest
DJ
Apr 16, 2014

I see that 4% number thrown around, but I cannot verify it anywhere. Can someone point me to the source?

Guest
Apr 16, 2014

This may help:
http://content.healthaffairs.org/content/29/5/806.abstract

It’s hard to know how much of “charges” actually has to do with actual health care because there is a huge, huge portion used for non-medical expenses (administrative and legal costs, infrastructure, corporate profits, shareholder profits, executive compensation and other benefits, costly disposables, designer drugs — you get the picture). And don’t forget the numbers typically don’t include optical, dental or mental health expenses which most American’s don’t think of as “healthcare dollars.”

Guest
LeoHolmMD
Apr 16, 2014

Smart. I hope this gets things turning around.

Guest
bird
Apr 16, 2014

great post!

But why provide quality, difference making changes in peoples lives that will only hurt the bottom line of the hospital systems that most primary care docs actually work for now.

Instead: click a bunch meaningless widgets, get meaningless stamps of approval from meaningless paramedical agencies and call yourself a meaningless medical home for whatever that means.

i applaud you practice and would love to set one up but the hospital has me captured for 1 year and 10 miles. Because you know if one internist left our hospital system with over 16,000 employees it would cause them significant financial hardship

Guest
privatedoc
Apr 16, 2014

Another exposition upon the Atul Gawande lame analogy. Consider for a moment, the NASCAR “team.” This consists of the owner, sponsor, team manager, crew chief, car chief, engine specialist, tire specialist, engineer, general mechanic, pit crew, trucker, etc.. Oh yes, and the driver.
Out of all those individuals, the only one who gets the idol worship, fame, fortune and girls (or boys) is the driver, partially because the driver is also the one who has most at stake if they lose.
No one really gives a crap about any of the other team members, who are essentially anonymous to the general public.
And furthermore, if you asked any of the other team members if they would rather have their job or be the driver, I think you know what would they say most of the time.
Same concept holds for fighter pilots on aircraft carriers, classical music soloists, etc.

Guest
FDR
Apr 19, 2014

Not sure I get your point. I see the sarcasm, but what’s the point?

are you asserting that the rest of the team wants to be the MD?

I’d rather not have the debt, or the responsibility and pull in the hefty salary of the RN!

Guest
William Palmer MD
Apr 16, 2014

Huddling is very Important as you aver. The wisdom of crowds will get you the acute intermittent porphyria diagnosis instead of appendicitis. It’ll find the bird allergy in a hypersensitivity pneumonitis. We need lots of brains to get us the correct diagnosis and intervention. And don’t forget to use the patients brain. This is called the “history”.

Guest
Apr 16, 2014

agreed entirely. We work with many High Performance Primary Care groups that have eliminated FFS in favor of a flat fee primary care or shared savings model. Almost half of them are building their own EHRs and supplementing it with analytic tools like ours (Amplify Health) because current tech is optimized for FFS billing.

Our data suggests that shifting the culture to a team based approach is effective but only if it is amplified (ahem) through technology. Culture shifting alone doesn’t appear to be nearly as successful in focusing resources on the neediest patients.

Very excited to watch the progress of all of these new primary care groups.

Guest
Scott Briggs
Apr 16, 2014

Hi Eric.

Can you elaborate on your comment about using technology to amplify the cultural shift to team-based approaches?

Guest
Eric Page
Apr 18, 2014

it’s easy to huddle on the patients that are coming in today, or that were in the office recently, but much more difficult to optimize resources around an entire patient panel if you don’t have good access to data on the deviations between what you expected patients to be doing outside the clinic and what is actually happening (e.g. ER / hospitalizations)

Guest
Perry
Apr 16, 2014

Primary Care practices now have to compete with Walmart and CVS docs in the boxes. Admitedly, many minor illnesses and injuries can be managed by these types of providers, for less cost and less wait.
What primary care has to do is now assume care for the costly, complicated patients that cannot be seen and treated immediately. It behooves practices to look for models that will allow continuity and value to the patient, independent of outrageous requirements from government and insurance agencies.
If nothing else comes of the massive shakeup in the health care system, may doctors be able to break away into models that can benefit patients, yet avoid some of the non-clinical activities that take up so much of physicians’ time.

Guest
Ryan
Apr 16, 2014

Let’s say I’m a VC/philanthropist and have, oh, a few billion dollars to throw at our health care system and I like your Idea.

I listen to your pitch and say: sounds good. Sounds great, actually.

But how does it scale?

Serious question, though I think the logical end is single payer. Keeping all of the dollars in one ecosystem allows for the alignment of incentives, high-ROI investments — and admin savings — you outlined.

Guest
Apr 16, 2014

So they said Zappos wouldn’t scale and they’ve done pretty well

This is essentially HealthZappos

Guest
Ryan
Apr 16, 2014

I don’t quite see the Zappos connection (and yes, I do -know- the connection), and I was not diminishing Turntable Health. In fact, I think they’re doing everthing right!

My point was broader: I think that this is a great model (won’t rehash the original post). But much of the model’s greatness is predicated on a pool of dollars being distributed with a rigorous and practical analysis of a) what drives the best outcomes at b) the lowest total cost.

The largest possible pool of dollars is national health insurance, with provider groups such as TTH each creating their own operating plan within it.

Guest
Jeff Goldsmith
Apr 17, 2014

Zappos sells shoes. You have merchandising leverage to help your margins in a business like that. You cannot buy any of the inputs into primary care more cheaply if you have 100 primary practices. It’s not yet clear if ANY of these new primary care models, direct-pay, direct to employer, you name it, actually do scale.

I keep hearing the “single payer” canard everywhere, as if the recent health reform debacle doesn’t comprehensively indict our federal government’s ability to implement ANYTHING. Who’s the single payer- the government of Sweden? It’s OUR federal government that has to implement it and our Congress that has to “architect” it. Even if the Repubs were’t trying to starve health reform in its crib, the Dems would still have screwed it up.
Our health system is $3 trillion dollars.

Does anyone honestly think our federal government can “run” a $3 trillion economic activity if it cannot even purchase its share of the present system sensibly. Dream on, single payer-ites. It isn’t happening.

Guest
MG
Apr 17, 2014

No but the Dutch, Israelis, and Taiwanese all have much more sensible healthcare insurance models and in the process have much lower costs on that end.

There will just never be the political will here due to the heterogeneous population in the US nor the fat (eg private sector profits) that would have to be cut to enact such a similar system.

Guest
Bill Springer
Apr 17, 2014

A single national payer model might not work very well, but how about a state or county-based model? This is how other countries (Germany; Canada) have opted to attack single payer to avoid diseconomies of scale.

Guest
John Irvine
Apr 16, 2014

Obviously different in many ways, but the emphasis on team culture, customer service and building an engaging tech solution sounds pretty familiar

Your other points are fair ones

Guest
Apr 16, 2014

ZUbin
The Nevada Health CO-OP eligible for federal subsidies on the state health exchange you mention–is this just wraparound? I am assuming the subsidies buy a plan with full EHBs, yes?

Your plan fills in the edges or you provide similar services, but in a difft fashion?

THanks
Brad

Guest
Apr 16, 2014

Hi Brad,

CO-OP provides full “wraparound” insurance, with us as the primary care for those particular plans. So patients can choose the plans on or off exchange, and then use us for all primary care with the wraparound covering everything else. We receive a capitated rate from the CO-OP. Hope this answers your question!

Guest
Matthew Holt
Apr 16, 2014

I like jar jar Binks…..

Guest
Apr 17, 2014

Me-sa thinking you-sa crazy!

Guest
Apr 17, 2014

I think we are somehow brothers. Either that or you stole all of my ideas. I can’t decide.

Guest
Apr 17, 2014

All of the above. Although most of my thievery is directed at Rushika Fernandopulle and Iora Health, I make sure to save some for Dr. Rob as I’ve been following your exploits for years, brutha.

Guest
Apr 17, 2014

Zubin, other that your poor evaluation of Star Wars characters, I think what you have going is fascinating.

What I would find really interesting is what there is more to Turntable than what Rushika & co have done elsewhere. In other words is this an Iora Health franchise model, or is it Intel inside, or Apple/Foxconn, or a Star Wars Disney version, or some other metaphor,

I’d love to hear more details on what Iora brought and what you added. (Either in the comments or in a separate piece about the nuts & bolts of your setup)

Guest
Apr 17, 2014

We like to think of it like this: our Turntable hardware and network runs the Iora operating system (iOS). So Iora hires the docs/coaches/nurses/social worker and runs the clinical operations, and Turntable builds the physical clinics, runs the marketing and patient payment portals, negotiates the contracts with health plans, employers, and individual patients. In addition, Turntable may create the associated speciality networks, hire hospitalists, etc.

To belabor the star wars thing, Turntable is the light saber and Iora is The Force. OK, that was stupid.

Guest

Sounds like a good model. Now, how is it different from a smaller version of Kaiser? (You don’t run your own hospitals, obviously.)

I ask because KP has leveraged tech, capitated payments, team, etc. And although it’s a good system overall, most primary care visits are short, PCPs are worked pretty hard, and patients have mixed feelings. (“You’re nothing but a number there” is what I heard from one.)

Regarding reimbursement, agree w Rob that there’s something to be said for having to justify one’s service just to the patient, and not to a 3rd party payor.

But what if that didn’t mean direct-pay? States have turned to “Cash and counsel” for some Medicaid non-medical services. It could be an option for patients to control their primary care cash, and they could decide to sign up for Turntable, or Doc Rob, or DocTalker, or whomever has the arrangement that makes them most comfortable.

I would not make this the default because for many people it’s a burden to decide on the spending, but would be interesting if it were an option people could exercise.

Guest
Apr 19, 2014

Leslie, excellent points and question. Re: Kaiser, yes they have certainly explored this territory. A full accounting of the challenges Kaiser faces is beyond the scope of this commentary, but a short answer for us is: focus the resources on primary care first (ensuring longer visits and appropriate care resources, leveraging non-clinicians maximally as well as asynchronous communication), ensure you have a scalable collaborative culture from the get-go, focus on quality and not necessarily on being the cheapest up-front option, and hire the right folks. Challenging, yes, but doable if you’re starting from the ground up and remain relatively nimble.

Guest

I think you definitely have an advantage in starting from the ground-up with a fresh team.
Keep going!

Guest
Apr 17, 2014

If Zubin is like me, it’s not a question of who pays for care; it’s about changing the model for primary care. I personally don’t want to ever take money from 3rd party payors, as it lets them demand proof that they are getting “their money’s worth,” which is what has created the coding and documenting chaos we now have. If the patient is the consumer of primary care services (which they are not in ANY third-party system), then they are the judge of the idea of “money’s worth.” The joy of living in this kind of practice is that there are no third-party eyes snooping at our care to determine if we are doing good enough; we work for our patients. Obviously, insurance for catastrophic care is still important (I don’t expect to ever see “direct care hospitals”), so an insurance system will need to exist, but the goal of the primary care system will be to prevent unnecessary use of that insurance. That is what patients want and it is what insurers want.

Am I right, Dr. Z?

Guest
Perry
Apr 17, 2014

I don’t know about Dr. Z, but I absolutely agree with you on that Rob.

Guest
Apr 17, 2014

Word, Rob. I do take money from Nevada Health CO-OP because it’s a very akin to our membership fee, they’ve been great partners (and are not-for-profit), and it allows us to extend our model to folks who would never be able to afford the monthly fees in the absence of the federal subsidies they are receiving for their CO-OP insurance. But I hear you overall.

Guest
Ryan
Apr 17, 2014

Rob –

Dr. Zamania said “We receive a capitated rate from the CO-OP.”

…Which is a third-party payor.

Pure self-pay primary care models are -exceedingly- rare in modern health care economies.

If you want to get there, godspeed, because I know of no other developed country that has adopted one.

If we accept that there will always be someone/thing in between your patient and your reimbursement, the goals should be to a)pay as little as possible in overhead/admin (admin costs of HC are a staggeringly large proportion of our HC $ spent) and b) align incentives to create best outcomes at lowest cost.

As for the issue of implementation, yes, Healthcare.gov sucked, but ultimately this will/would have little to do with what the government looks like as a payor. If you want to know what that looks like, check out the VA or Medicare.

So forget diseconomies of scale – I’m not suggesting that we nationalize providers or facilities – but it seems like medicare is working -pretty- well, overt politicization aside, and layering a national insurer/payer over a network of providers that look like Turntable Health seems to pretty clearly meet both criteria I mentioned above.