Physicians

Rebooting Primary Care From the Bottom Up

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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Sari GraenFDRLeslie Kernisan, MD MPHDoc EpadorBill Springer Recent comment authors
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Sari Graen
Guest

AWESOME

William Palmer MD
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William Palmer MD

@Ballard
Perhaps this could be studied. I.e. is drug advertising appropriate?
Diabetes experts can tell us what percentage of type II diabetics should be on Metformin. Are ads for Metformin excessive compared to the ads for other oral drugs for diabetes II ? If they are way out of line, then we might know that Pharma is tryikng to screw with our heads. But they may simply want to advertise drugs which yield great profits–can’t blame a businesss for that, can we? So, maybe this is not such a good way to study it? Forget this post if you want. ;=).

William Palmer MD
Guest
William Palmer MD

@Ballard Were’nt you surprised at how the drug companies put all the contraindications and side effects out there, blatantly, in their ads? It borders on ad nauseum It’s quite counterintuitive but it shows extreme acuity to do this as the non-obvious reason is to build up trust in the public. It does with me. And, all this stuff was done with focus groups first, I bet. I’m not so sure that any harm is done by advertising drugs. We naturally do not want to whet inappropriate demand and hence raise prices, but are we sure this is true? Maybe it… Read more »

John Ballard
Guest

“Rebooting primary care from the bottom up” is a great idea, but one of the biggest barriers facing medical care in general (including primary care by default) is the impact of advertising. Some of us are old enough to remember when the idea of advertising prescription medicines was unheard-of. Whenever I hear one of those “be sure to tell your doctor” advisories it makes me wince. We need to tell the doctor about our signs and symptoms, family history or all kinds of personal stuff — but if we have all our medical care ducks in a row we don’t… Read more »

Ryan
Guest
Ryan

Finally, I apologize to ZDogg for turning the conversation towards financing rather than care delivery systems, but I believe that the two are fundamentally linked: the current financing system makes the unification of patient and provider incentives — in the way that Turntable Health IS doing — very difficult indeed. Hats off to them.

John Ballard
Guest

Thanks for this.
If as much energy were spent seeking competitively-priced health care as competitively-priced insurance the price of both would be better controlled.

Zubin Damania
Guest

No apologies needed, it’s a great discussion! Agree about fixing the financing, it’s crucial to everything. Another interesting angle is philanthropy: I can think of fewer more efficient uses of foundation or philanthropic money than to purchase memberships for disadvantaged patients with chronic diseases. Benefits go to the patient and to the rest of the system, which saves untold dollars in preventable ER and hospital visits.

William Palmer MD
Guest
William Palmer MD

@Rob I’ve always liked the concept of county–hospital-district single payer without any third party–or its apparatus of billing or claims. Non-ambulatory care would seem free.This would apply to hospital care only and people would have to manage ambulatory care themselves using any payment technique or insurance they wanted. You might recall that Canada tried this early on. I.e. it covered only hospital care initially. Triage at the front door would consist of asking three questions: could this patient’s illness kill him? or disable him? or bankrupt him? If the answer to any of these is yes, the patient would be… Read more »

Doc Epador
Guest

I am old enough to have seen, worked and trained in City and County healthcare facilities. I have worked at the VA and I am a VA patient. I have absolutely no idea why anyone would think those systems are the way to go, unless you want to go downhill. Fast. Or they just don’t know their medical history.

William Palmer MD
Guest
William Palmer MD

@Epador The hundreds of insurers are killing us. Our minds are distracted by ICD 10s and EHR compliance. The hospitals can’t focus on patients because they are focusing on foundations and fund raisers and new programs to gain market share. The health care providers are metaphorically climbing Everest and the line of a 1000 porters–aka stakeholders–behind them have to eat. The business of medicine and the regulations of medicine are overwhelming the science and art of medicine. Where are we now? , if not downhill? Besides roughly half of the health care dollar is ambulatory and I let this loose… Read more »

Doc Epador
Guest

Its the regulatory environment the insurers live in, not the number that is the problem. Why do I have to be credentialed BY AN INSURANCE COMPANY if I am credentialed by the State? I am waiting 4 mo for Medicare to allow me to bill as a par provider at my new location after 35 years of practice without a blemish. That is crazy. And single payor will be worse. Why subsidies for the poor (more taxes) and not local sliding scale/charity handled by the community?

Ryan
Guest
Ryan

Isn’t it quite plausible to imagine a unified state/payor licensure/credentialing system if the state and the payor are one in the same? It seems that you are using an indictment of the current, fragmented, system, to oppose a future consolidated/rationalized system. See: “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers” (http://content.healthaffairs.org/content/30/8/1443.abstract) As for why not simply use more charity care: we already have charity care and it’s a defining feature of the current system; indigent care in any setting (though obviously ED/inpatient is the real $ killer) is “charity”. Ultimately you, me, and… Read more »

Doc Epador
Guest

Well, I don’t see a reply button for you Ryan, So I will reply in the thread here. 1) It is quite plausible to imagine a unified state/payor system. It doesn’t look pretty to me. 2) I am indicting the portion of the system that has increased rather than decreased complexity, further alienated the patient and the provider from each other. I am not promoting throwing out the baby with the bathwater. If patients were truly allowed to consider various [real] insurance options, and providers/patients were allowed to negotiate services free of government intrusion, that also might improve the system… Read more »

FDR
Guest
FDR

How Being a Doctor Became the Most Miserable Profession http://thebea.st/1sY36mA

You are correct.

John Ballard
Guest

You’re a VA beneficiary?
If the VA is that bad why not leave the system?

Doc Epador
Guest

Right now I am working from within as a patient to try to improve the system. I have a much stronger voice as a patient and physician than as an outsider avoiding the system.

With a $110000 deductible the most favorable insurance product I can obtain (thank you Mr O) although I can access care outside the VA system, it makes economic sense for me to continue there.

That good enough for you?

Doc Epador
Guest

whoops, 11000 deductible. I think the 110000 version doesn’t start until after the next Presidential election.

Ryan
Guest
Ryan

It’s too bad there isn’t something you could have paid into with reasonable premiums over the course of your whole life that would have provided first-dollar coverage now, instead of your being faced with an insurance policy with an $11K buy-in…

Snark aside, I do want to reiterate – especially since you have said that you want to be involved in CHANGE – that you (and you are certainly not alone) are using complaints/problems DEFINITIONAL of the current system to indict a future system that would not likely share those same problems: non-sequitur.

William Palmer MD
Guest
William Palmer MD

Your one hundred ten thousand deductible typo is not so far off these days….;=) The actuarial value of a plan is the percentage of ‘covered services’ that the plan will pay, on average, for a group of patients. It can be thought of as the generosity of the plan. It’s a statistical term and it doesn’t mean that an individual patient will have to come up with co-payments and co-insurance and deductibles exactly equal to his share in the AV calculation. It could be a little more or less. You can think of the word “covered” as meaning the normal… Read more »

Rob
Guest

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… Read more »

Perry
Guest
Perry

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

Zubin Damania
Guest

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.

Ryan
Guest
Ryan

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… Read more »

Matthew Holt
Guest

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)

Zubin Damania
Guest

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.

Leslie Kernisan, MD MPH
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… Read more »

Zubin Damania
Guest

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.

Leslie Kernisan, MD MPH
Guest

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

Rob
Guest

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

Zubin Damania
Guest

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.

Matthew Holt
Guest
Matthew Holt

I like jar jar Binks…..

Zubin Damania
Guest

Me-sa thinking you-sa crazy!

Brad F
Guest

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

Zubin Damania
Guest

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!

John Irvine
Guest
John Irvine

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

Ryan
Guest
Ryan

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.

John Irvine
Guest
John Irvine

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

This is essentially HealthZappos

Ryan
Guest
Ryan

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… Read more »

Jeff Goldsmith
Guest
Jeff Goldsmith

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… Read more »

MG
Guest
MG

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.

Bill Springer
Guest
Bill Springer

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.

Perry
Guest
Perry

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… Read more »

Eric Page
Guest

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… Read more »

Scott Briggs
Guest
Scott Briggs

Hi Eric.

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

Eric Page
Guest

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)