The aha moment for Rushika Fernandopulle, MD, MPP, came during his internal medicine residency at Massachusetts General Hospital in the 1990s. After a full day of seeing dozens of patients in seven-minute increments, he was talking late into the night with a colleague as they were completing electronic health record (EHR) documentation. Frustrated by the volume of bureaucracy imposed on physicians, a fee-for-service model that seemed to encourage superfluous tests and procedures, and a lack of patient care time, Dr. Fernandopulle’s colleague blurted out, “Every day I lose a little piece of my soul.”

To which Dr. Fernandopulle immediately responded, “You’re right. We went into this to help people.”

It took a number of years in practice for Dr. Fernandopulle to hit upon a way he believes can right the wrongs he and his colleague bemoaned during their training days. In 2010, he co-founded Iora Health, a Boston, Mass.-based health care company, and completely dispensed with the fee-for-service structure and the seven-minute primary care patient visit. Dr. Fernandopulle, who serves as Iora Health’s CEO, has said that the company’s patients occasionally spend an hour with their primary care health-care team.

There is more time for direct patient care, he told AMA Wire®, because Iora physicians have lighter patient caseloads. Iora “providers have half the number of patients as typical doctors,” said Dr. Fernandopulle, who will give a presentation entitled “Relationship-Based Care: Healthcare That Really Puts the Patient in the Center” at the Collaborate in Practice Conference, April 9–11 in Chicago.

The conference is co-sponsored by the AMA and the Medical Group Management Association, and registration is still open. Meanwhile, the AMA Inspirations in Medicine event—April 10, 6:30–9 p.m. CDT, also in Chicago—will offer at "taste of TEDMED." Learn more and register.

Dr. Fernandopulle explained further that the Iora model also enhances patient care because a team of nurses, behavioral-health specialists and health coaches who are (sometimes) nonclinical but always hired for their empathy. Health oaches are individuals hired from the local communities in which Iora practices are situated. The team works closely and collaboratively to address patients’ health concerns and needs. 

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“For example, as doctors, we could all tell someone that we think it’s important for him to lose weight to reduce the risk of developing type 2 diabetes,” Dr. Fernandopulle said.

“But what if there were something in that person’s life that is preventing him from doing so?” he added. “Ultimately, what’s important to me as a doctor may not be important to that person, for one reason or another. The way our care is delivered makes it more of a conversation. Patients feel comfortable explaining why they can’t lose weight, whether it’s financial woes or another reason. … More often than not, the patient confides in his health coach as a confidant. He is comfortable telling us because we spend time getting to know him in sometimes hour-long appointments. It really just boils down to time.”

But time is money. How does Iora sustain itself on a model of longish patient visits without the guarantees of remuneration from the fee-for-service paradigm?

The answer is that Iora essentially operates in a value-based model of care—aiming to deliver concierge- level service without additional cost to the patient or health plans. They pay Iora a flat, fixed fee for primary care services in addition to sharing the value created from better health outcomes and lower costs for downstream care such as hospital days, specialist visits or procedures.

There are about two dozen Iora practices spread throughout the country. Most are either on the East Coast—in New York or New England—or throughout the West, including Washington, Colorado and Arizona. All aim to serve specific communities. The majority of the practices are dedicated to serving seniors through partnership with Medicare Advantage plans.

Additionally, the Grameen Vida Sana clinic in New York’s borough of Queens provides care to a population of female patients that is mostly undocumented and uninsured. Iora’s Dartmouth Health Connect in New Hampshire is open to employees of Dartmouth College, King Arthur Flour, and members of the New England Carpenters Benefits Fund, as well as their families.

The specificity of the patient population is intentional, said Dr. Fernandopulle.

“Primary care is actually very different depending on the population you serve—building the right primary care for seniors is different than building it for young, healthy people, or for people at the end of life,” he said in another interview. While the Iora model aims to provide excellent care for patients of any age, it can be particularly effective for patients 65 and older who have more chronic conditions and need more care coordination.

Not every experiment has succeeded, Dr. Fernandopulle acknowledged, and a few Iora practices have closed. But it is a relentless commitment to finding a better way to deliver primary care that keeps Dr. Fernandopulle and his colleagues at Iora going.

“We are going to keep working hard to restore humanity to health care. We continue to improve on our model, outcomes and the experience for both patients and doctors,” he told AMA Wire. “Our goal is to transform health care—not just for our patients but for all patients, by showing a very different and better model of care.”

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