Dr. Rushika Fernandopulle, Co-Founder & CEO, Iora Health
We’re on the cusp of big changes in how healthcare will be delivered. What does it look like? Dr. Rushika Fernandopulle, a physician, co-founder and CEO of Iora Health, challenges the status quo as he lays out a detailed approach on how to deliver a highly personalized and accountable ‘health’ experience with a shared care plan.
Dr. Rushika Fernandopulle is a practicing physician and co-founder and CEO of Iora Health, a venture backed, national de-novo primary care group based in Boston MA. He was the first Executive Director of the Harvard Interfaculty Program for Health Systems Improvement, and Managing Director of the Clinical Initiatives Center at the Advisory Board Company. He is a member of the Albert Schweitzer, Ashoka, and Salzburg Global Fellowships. He is also an Aspen Health Innovators Fellow. He is co-author or editor of several publications including Health Care Policy, a textbook for physicians and medical students, and Uninsured in America: Life and Death in the Land of Opportunity. He serves on the staff at the Massachusetts General Hospital, on the faculty of Harvard Medical School, and on the boards of Families USA and the Schwartz Center for Compassionate Care. He earned his A.B., M.D., and M.P.P. (Masters in Public Policy) from Harvard University, and completed his clinical training at the University of Pennsylvania and the Massachusetts General Hospital.
Show Notes
What if there is a completely different model of healthcare delivery starting with primary care? [02:10]
Five different aspects that need to change in the next 30 years in order to advance healthcare delivery. [03:26]
What is a shared care plan and how can it benefit both the patient and doctor? [06:55]
Will the most common interaction between patient and doctor be virtual or in person? [09:48]
What should we teach medical students now in order to achieve a new vision for 2049? [11:57]
We need a shift in mindset, medical training models and the way we choose prospective medical students. [14:06]
How do we ensure that we achieve that equitable future? [15:52]
What role will hospitals play in the future? [18:22]
Will hospitals become abandoned towers, the same way manufacturing facilities were affected by deindustrialization? [20:34]
How will health insurance companies evolve to adapt with the changing times? [22:32]
How do we create a different vision of primary care to attract talented doctors into the field? [25:00]
Three areas in health care that have already made advancements. [27:00]
Health is really important on three levels that not only affect the individual, but also our society. [28:38]
Transcript
Jason Helgerson: I'm Jason Helgerson and you're listening to Health2049.
Dr. Rushika Fernandopulle: I think it starts with simply a commitment that we want to build an equitable health system. And it's not clear we actually have that commitment at the moment, or it's certainly that we're acting on that behalf because it means that we would make very different decisions about how we do that.
Jason Helgerson: Today’s guest is someone who has dedicated his career to bringing empathy back into American healthcare. Currently, he is serving as the co-founder and CEO of Iora Health, where he is literally in the business of building a more equitable healthcare system. He believes that all individuals, regardless of race, income, or zip code, have the right to access highly personalized and accountable care. Given all his work to date, I can't wait to hear what he thinks healthcare should look like 30 years in the future. It's my pleasure to welcome Dr. Rushika Fernandopulle to our program. Rushika welcome.
Dr. Rushika Fernandopulle: Thank you. It's great to be here, Jason.
Jason Helgerson: Great. Well, why don't we start with you telling our audience a little bit more about your interesting background.
Dr. Rushika Fernandopulle: Sure, so I'm a primary care doctor, and I think, well over 30 years ago, you know, it's hard to be a primary care doctor and not realize that the system doesn't work. They're largely good people and good intentions, but the system is really not doing what it should do, which in theory, the reason we have a healthcare system it's to actually improve our health and we've gone astray. So I tried doing what everyone else is doing, what I call the incremental change model of trying to tweak the system and working for a big health system and serving on various committees, and trying to go to Washington and work on the policy side, worked for a consulting company. I worked in academics and ran an inter faculty health policy group at Harvard.
And finally came to the conclusion, maybe what we need to do is simply start over and build a new system from scratch. And that's what really led me eventually to building Iora, which is trying to do exactly that. What if there is a completely different model of healthcare delivery starting with primary care? Let’s just build that, get patients to vote with their feet, and that will perhaps change the system.
Jason Helgerson: Well, great. So given all you've done in the time you've been building Iora and with that building a healthcare system, obviously that gives you a great seat for looking into the future. And so I'm going to next ask you the question we ask all our guests, which is what does healthcare look like in the year 2049?
Dr. Rushika Fernandopulle: Yes. I actually think we're on the cusp of healthcare looking very different. You know, it's funny if you go back 30 years instead of forward 30 to 1980, to be quite honest, not a ton has changed. Like, yes, we have computers and yes, we've got better technology, but the way we deliver it to people is actually fairly similar, I think the next 30 years, it's going to bring a really big differences and maybe a five or six stakes.
The one is, I think healthcare will be a much more personalized. We are now beginning to learn about genomes and proteomes and microbiome, so the way we do healthcare now is incredibly, you know, that there's population health is maybe the wrong thing to do. It’s a, we do a study and we say that 51% of people benefit from beta blockers, by the way, that means that 49% don't, but we then recommend everyone get beta blockers. We say everyone should get them. Every woman should get a mammogram every year or every two years. And it turns out that some that's probably right for, some people too often, other people it's actually probably not often enough. So I think we will learn and be able to personalize our recommendations to people much better based on who they are.
Second, I think there'll be a very different role of technology. I think a lot of the routine stuff we do right now in healthcare, what can be protocolized will be done by a computer and AI. There's no reason for it, by the way, that doesn't mean that it's going to replace doctors. There's some Silicon Valley people who talk about that. I think there's a huge role, which we can talk about where human beings still play. But I think we're going to really say, let computers do what they do well and let the people do what they do well.
Third is, I think care has got to become more accountable. We right now have a healthcare system that's based on transactions and largely a fee-for-service payment model. And so what we do is, we do more stuff to people, not make them healthier, not helping them live better lives. And I think the organizations that start being accountable, already we're seeing this and people like us and others just have such better outcomes, and that customers, patients, will vote with their feet, so much more accountable. I know this accountable care has been a buzzword for a long time and despite the hoo-ha, it's not very present today. Only about one and a half percent of most health systems revenue comes to real accountable payment. I think that will change radically in 30 years.
Then related to that, I think we'll focus more on health than healthcare. In the end, the goal of the healthcare system should be to make us be healthier, you know? And I think it's very clear that many of the improvements in health have little to do with healthcare. It has to do with sort of social interventions, optimism, sense of purpose, social connection, how we eat, how we move, relationships, stress, and I think we'll start paying much more attention to it.
And then finally, and maybe this final one is a bit of a hope because I could see us going two ways, but the system is more equitable. And I think we can go two ways. Unfortunately, the way we're going now with our healthcare system is becoming more and more inequitable. The haves have more and the have nots have less. And we see that with COVID. We see that in the way we're giving out immunizations for COVID. We see that with what people now call social determinants of health. We can fix that. We know how to fix that. I think that's going to take some political will and I would like to hope, and we're doing everything we can to say, no, let's actually try and make the system more equitable. So it's really a personalized, a different role for technology, accountable, health-focused and then equitable
Jason Helgerson: To help our audience, who’s a mix, some of them are deeply rooted in healthcare and others are not, help our audience sort of wrap their heads around this future state that you're describing. If you could, please describe that future world from either the perspective of a patient or a provider.
Dr. Rushika Fernandopulle: Yeah, let’s do it from a patient point of view because I think that's the most important. For too long, we've designed our healthcare system around the provider, no other industry does that. We should be designed around our customer. The customer, to be really clear, are the patients, not the providers, not the health plans, not the pharma companies, it's the customer, the patient. So I think if I was a patient, it's important for most people that you do still have a relationship with someone who is going to quarterback your care. We think primary care is a great way to do this, but you can imagine maybe some other sort of vehicles. But a human being, a doctor who is my go-to person who can help me coordinate everything.
What we do is called a shared care plan, which is a proactive plan designed just for me about what I should be doing and is based on my genomics, my proteomics, my microbiome, my wishes and preferences, my genetics, all those things. And this is what I want to do to improve my health. And it's going to be a plan about how I eat, how I exercise, how I build my relationships, the medicines I take, what I'm monitoring and the like. I think I will have access to both human beings and technology to help me execute on that plan. So, sensors will be picking up on my blood pressure, my stress levels, my activity levels, et cetera, and providing feedback to me and if it’s sort of simple feedback, that will largely be automated. But when it goes off the rails, then the human will get involved and say, hey, I noticed that your blood sugar is going off the rails. Let's talk about what we need to do to make this better. And so over the long period of time, I will be able to sort of improve my health, improve my life based on my goals and the like.
From the provider point of view, this is a much better world. This is why we went into medicine, not to do more stuff to people, not to be fighting with billing and coding, all of that stuff will get automated and hopefully even go away. But it allows us to take care of populations, get to know them and do the stuff that only humans can do. If you ask the question right now for primary care docs, what percent of your day is spent doing things that only you can do with all your training and experience? The answer is probably 20 or 25%, and 75% is just crap that we can have either other people or more importantly systems do. So I think from both the sort of patient point of view and the provider point of view, this is a much better world.
Jason Helgerson: So in the year 2049, do you see the typical interaction between patient and provider as a virtual interaction in the sense that becomes the default? Obviously for a long, long time the default has been that we as patients go to the provider to receive services, but do you see that default being that sort of virtual visit as opposed to physical, or do you still see the physical visit as the most common interaction that an individual has with the healthcare system?
Dr. Rushika Fernandopulle: I think it's actually the wrong question you're asking because the right question is not about how we do it, it’s how do we meet the need best? And so we're doing this right now. On average, our patients at Iora have 19 interactions with their doctor or their health system in a given year. Of those half of them, about 10 of them, are what we call asynchronous, which is emails or texts. It works really well. We don't have to be on at the same time. It's very efficient. And then half of them are synchronous, meaning we're interacting at the same time. Of those, let's call it again 10 to be a round number, four in person, four are by video, two are by phone. And the principle we use Is, if the right way to do this interaction is in person, then by all means let's do it in person. If the right way to do it is by video, then let's do it by video. If we can do it by a phone call, let's do that. If it's an email or text, let's do that. The reality is that different interactions actually need different things.
Why do we need to be in person? It's clearly to build a relationship. We think it's important. I think one thing COVID has proven to us is that just the nature of relationships that one can build when we meet in person is very different than simply meeting people on video. And I think anyone who has done online dating probably knows that. So we want to meet people in person at least once.There are a set of conversations which are better in person. Serious conversations about end of life care, we should do in person. We also think there’s some clinical things where I need to lay hands on you. I need to feel your belly. I need to listen to your lungs. And yes, we can do some of that by technology, but some of it requires just laying on of hands. We've done that for thousands of years, it’s important. Now a huge chunk of it is not, by doing by video and text. So again, I think the key is we should drive how we interact with our patients, or our doctors if you're a patient, by what the best way to do it, and the right answer is we will use all of them. That'll be sort of a pallet we can pick from depending on the right way to do it.
Jason Helgerson: Do you think that the way we train doctors today is consistent with the vision that you have for the future? Or is there a need to change the actual methods, ways and subjects that we're training the physicians of the future around?
Dr. Rushika Fernandopulle: Oh, absolutely we have to change. I think the current way we train physicians is completely outdated. Remember that a typical practice today, your job is, I walk in the door in the morning, I have 31 or 35 or 40 patients booked. I see them for seven minutes. I do the best job I can. I document code to bill it as high as I can. I turn my brain off. I go to the next patient. And I do it all myself. It's largely based on my own knowledge that is stored in my head. That's not what we do. Our job and the job of, I think the healthcare delivery system of the future is that I have a population of people and they are my responsibility. How do I improve their health, keep them out of trouble and do whatever it takes with this whole panoply. Why are we teaching doctors organic chemistry? Why do we require BC calculus? It's ridiculous. I've never used any of that stuff.
But what we should be teaching is behavior change, how to use data, how to manage teams and how to think about populations. It’s a whole separate set of skills. I think the teamwork thing is really important and then the data thing. So really what we're doing is managing populations and how do I think about that? I'm about to take a recertification test, which is a closed book test for eight hours where they're testing my knowledge. It’s ridiculous because in real life, you look stuff up, you use peripheral brains. This is all available to you at your fingertips. I think that the way we need to cram a bunch of facts in people's heads and then regurgitate it, it’s completely crazy in 2021. We need to evolve all of those and how we look for who is going to be a good doctor. How we train them and then how we sort of test them and keep them up to date, all of those need to change.
Jason Helgerson: How concerning is it to you that the physicians who are in medical school today are going to be the heart and soul and at the peak of their careers in the year 2049, yet, really aren't getting the type of educational experience that you're describing?
Dr. Rushika Fernandopulle: Well, I think it's a huge problem. This is a bit of turning the battleship. And I think if we want to be ready for where we're going to be in 2049, we need to look ahead, you know, the Wayne Gretzky's way, where the puck is going to be, and really start changing the training models. I think people need to be exposed to different ways of thinking and different training. We need to pick different people. We need to train them differently. As I said, we need to keep them up to speed. And I think very few, if any medical schools are doing any of that or residency's. In the first year of medical school, they're doing some things differently and teaching some of this empathy and teaching some of the teamwork, but then what happens is the second you end up going to internship and residency, whatever benefit you had gets kicked out of you because you're just back in the old turn the wheels sort of system. I think we need to change it from soup to nuts, not just throw a few juicy tidbits into the first year of medical school curriculum.
Jason Helgerson: So the five aspects of that future state that you described, the one that you said was perhaps aspirational, at least you seemed most concerned about it actually being achieved by the year 2049 was equity. And obviously equity is at the top of the political discussion at the moment, particularly, as you mentioned, as it relates to the rollout of the COVID-19 vaccines. What do you think it's going to take to ensure that we have a truly equitable health system by the year 2049? Is it policy change? Is it new care models? Is it new payment models, all of the above? What do you think is really needed to ensure that we achieve that equitable future you hope is possible?
Dr. Rushika Fernandopulle: I think it's all of the above. It starts with simply a commitment that we want to build an equitable health system. And it's not clear we actually have that commitment at the moment, or certainly that we're acting on that behalf because it means that we would make very different decisions about how we do things.
Number two is that it requires us to change deep structural things. On the healthcare system part, I'll give a simple example, in Medicare advantage, which is where we work, there's a risk adjustment formula where you get paid more to take care of sicker people. There is no adjustment right now for socioeconomics or race. And we know that folks with poor socioeconomics and in minority groups that are traditionally disadvantaged have harder problems. A simple thing to do is add that to the risk adjustment formula and make it so that if you take care of folks who are disadvantaged, you actually get paid more. Guess what? Lots of people are going to flood into actually taking care of those people, as opposed to now where it's harder to do and therefore you don't do it because you get paid less or the same.
I think also a commitment about the uninsured. COVID has shown us this idea that we're all tied together and thinking that there are people we can not give good healthcare to and it won't affect the rest of us is silly. COVID is a great example where it affects all of us. It affects the economy. We’re one of the very few industrialized countries that have not made a commitment that everyone in this country ought to get reasonably good healthcare, regardless of whether you can pay for it, regardless of your insurance status.
We're still tying to this crazy World War II era where you link employment to insurance, which makes no sense whatsoever given the current state of the world and the patterns of jobs. I think we need to change that, too. Then there's a bigger issues, the real core problem is actually a systemic inequality that has nothing to do with healthcare. It has to do with education, housing, safety and pollution in disadvantaged communities. I think if we deal with this even bigger thing, we have to fix those things if we really want to make healthcare more health, more equitable.
Jason Helgerson: Let's talk about the actual infrastructure of American healthcare and start with one of the real behemoths of the system, hospitals. What role do you see them playing in American healthcare in the year 2049?
Dr. Rushika Fernandopulle: It's a great question. We will always need hospitals. There will always be a set of illnesses, particularly serious ones that will require you to physically be somewhere and have people “working on you,” keeping a close eye on you, to have access to advanced technology, whether it's intubating or pressors or the like. Now I think that will be a smaller and smaller percent. We have seen over and over again a 40% drop in hospitalizations by doing better primary care. On top of that, if you do need the hospital, there are people like Contessa and a number of medically home, which is showing that a good chunk of the things that people are now sitting in the hospital for, even if you can’t avoid it, can be managed in their house, hospital at home, by bringing a little technology to your house. I think what COVID has shown is if you don't need to be in the hospital, you don't want to be in a hospital. You will have a medical error, you will fall or break your hip. If you're an old person, you'll get some dread infection that floats around hospitals.
Do we need hospitals? Absolutely. I think they will be a lot smaller and this is a very controversial point, but they will be a lot smaller than they are now. They will need some percentage of the beds they have, but that number is going to be half or less, not 10% less. I think there are very few health systems, Mount Sinai’s is one that is committed to that. They said they're taking 800 bed towers and shrinking them to be 40 beds. We see very little of it. If I drive around, every hospital is putting up new bed towers. I think that’s misguided given where healthcare is going to be in 2049.
Jason Helgerson: Do you see the hospitals almost like the manufacturing facilities of the middle of 21st century with de-industrialization, what we see now, when you drive across certain parts of America, sort of abandoned old manufacturing places that used to employ large numbers of people? Do you fear at all that in the year 2049, we'll be looking at hospitals and seeing them as those abandoned towers because they're just no longer useful? Is that dystopian view a concern for you?
Dr. Rushika Fernandopulle: The one thing hospitals have is that they're sitting on incredibly valuable real estate. If you go to most places, the hospitals are in really nice areas. You're already seeing some of this in New York and in some parts of Boston, places with high real estate costs, you pull down that hospital tower and you put in place something else that is a better use of that land, whether it's senior housing or multi-use development or whatever. I think hospitals have a fundamental decision to make, the world is going to split into two groups. We have for too long driven healthcare around optimizing for providers. I think what's happening in healthcare, for a whole variety of reasons, is that it's going to be increasingly driven by consumers. It's a lot more consumer choice, whether it's through Medicare Advantage plans or high deductible plans and the commercial side.
So increasingly you will have two choices. You can either take responsibility for managing the health of populations. Or you can become a commodity provider of services to people like us who do that. And so I think hospitals as an institution, we'll need to start moving and say, you're going to manage populations. We're going to do what our mission statement actually says, which is improve the health of the community, not fill hospital beds. That's a fundamental difference. The successful ones start getting into different businesses, whether it's primary care, wellness, housing and a whole lot of other things which can improve the health of the community, which is much more than just building hospital beds or filling MRI machines or whatever it is. You see the really progressive ones that, the inner mountains of the world actually moving in that direction.
Jason Helgerson: Let's talk about the other big behemoth of American healthcare, which are insurance companies who obviously play a role in providing healthcare, access, buying healthcare services on behalf of commercially insured, Medicaid, Medicare, what's the role of the health insurance company in the year 2049?
Dr. Rushika Fernandopulle: I think that's very different too. What's happening now is you're having folks like us, which are physician groups, being able to raise capital and being able to build IT systems to be able to take responsibility for the health of populations. I think we do that much better than health plans because we have a real relationship with our patients. We meet them in person, we’re their doctor, we have real clinical information, not claims information, and we have a real affect, we can actually change care. In a world like that where you have organized, well-capitalized provider groups, it is not clear to me what the role of what a health plan is, to be quite honest. You could imagine a health plan starts becoming one of these middlemen who are taking a big amount of value out of the system that will get disintermediated. We've seen this over and over again the last 20 years, think travel agents, et cetera. I think health plans also have a reckoning about either we start really being clear about what the value we're adding and charging for that, but simply being a middleman and then taking a chunk off the top becomes less and less viable. And by the way, you see the smart ones. The great quote “the future is already here it's just unevenly distributed.” United Healthcare is obviously making a huge pitch this way, where they're participating with their Optum Group and going into all sorts of other businesses, including care delivery, analytics, managing drugs and providing housing. They're doing all sorts of things because they realize that's the future. It's not simply being a financial middleman and taking this sort of big 15% cut off the top.
Jason Helgerson: Another important aspect, particularly given your vision for the future is the role of the primary care provider in the system. One of the concerns today is a lack of primary care providers, not surprisingly primary care providers are under compensated compared to their colleagues who are specialists. And so 30 years in the future, are you confident that in order to achieve your vision, that we'll be able to attract enough people into primary care to allow these primary care centric models to exist? Will we have to convert specialists into primary care providers or do you see technology increasing efficiency to a point where we won't need the same kind of ratios that we have today in order to be able to provide that a high quality primary care experience?
Dr. Rushika Fernandopulle: Yeah, so the population is not just growing, at least in the U.S., but it's getting older and sicker. There is nothing any of us can do about that, the baby boomers are all aging into the time where they're gonna need more care, not less. I think for the foreseeable future, we're going to continue to need to have primary care doctors. Now, what's interesting is if you look at Europe, look at most of the world, there are twice as many primary care doctors as specialists and we have the exact flip here in the U.S., we have twice as many specialists as primary care doctors. I think that's a big problem. And it's because, as you mentioned, we have skewed the payment models for a variety of political reasons where specialists get paid roughly double what primary care doctors do.
But the other problem, I think, is that the job sucks as a primary care doctor. You need to have your head examined to go into primary care in the current model where you're on this treadmill, or you're not getting paid very much. You don’t have the right support. You have these crappy IT tools that make your life harder, not easier and there is no future. So I think that's why people like us are trying to build a different vision. We have no trouble attracting primary care docs because it's a better vision. And eventually the way the economics work, we'll be able to pay people dramatically more. And so that's where I think the world has to go. We need more primary care doctors. Yes, there are a bunch of folks at the low end of the acuity spectrum who probably could have many of their needs taken care of by either technology or less highly trained people. I think there are people at the high end who actually need more primary care. In the end, do we need more or less? I don't know, we’ll have to figure it out, but we certainly need many. And I think creating a different vision of primary care, it’s a better job, better tools, better economics will actually help us fix that. Now again, I talked about moving battleships, this is a huge change it's going to take years and years to do, but I think we can already start seeing the beginnings of it happen.
Jason Helgerson: All right, I hear you on the challenge of turning the battleship around, but what makes you confident, given all these challenges, that your vision is actually achievable in 30 years time?
Dr. Rushika Fernandopulle: I think the science is advancing. We’re understanding more and more literally every week and every month about genomics and about personalizing care. So science is advancing no matter what happens. I think there are economic imperatives that this will happen. If we don’t, the system will collapse. If we don't fix this out of control healthcare system we have in the U.S., we're going to bankrupt the country because of Medicare and Medicaid and we’ll bankrupt individuals, et cetera. The system will collapse. And third, the social imperative you had mentioned just more and more focused on inequalities. I think there are more and more people getting this and healthcare is a big part of it. Now, maybe on the pessimistic side is what will make this hard is that we have a very powerful medical, industrial complex who really has built themselves around continuing to do more stuff for people and these are the healthcare providers, the payers, the pharma companies. I think what we're going to see is a battle between consumers in the larger interest versus the medical industrial complex, or maybe the smart ones will decide they're going to align back with the consumers and they will win and the others won’t. Again, I think there are a lot of reasons to be optimistic, but it will not be easy.
Jason Helgerson: All right, so we always like to end our shows with this final question, which is really an opportunity to take a step back and imagining that your vision for 2049 health and healthcare is actually achieved and to think about it in the broader context of the country, of humanity and really why is achieving that important? In other words, how would achieving your vision actually make the world a better place?
Dr. Rushika Fernandopulle: Health is really important on three levels. Personally, it's a huge priority, without your health you don't have anything. So who cares how much money you have if you're not healthy. As we start to age, we really care about having a system that'll help us improve our health.
Number two is society. It's a hugely an issue of productivity. I think societies that are not healthy will not be productive. COVID showing us this. This is a health issue, it’s a tiny little virus that is running havoc with our economy and our mental health. So there is an issue of productivity.
Then finally it is ineffective spend that is bankrupting us. It’s spending money on things we don't need or want. I think almost anyone who looks at U.S. healthcare spending thinks that 30%, and some would say up to 50% of what we're spending is waste, and waste is not just things that are not necessary, but they may actually be creating harm for people. They're not just what we need or want, it may be harming us. And so I think we have to fix this problem. If we can, it will make a huge impact on making the world a better place.
Jason Helgerson: And that was Dr. Rushika Fernandopulle’s vision for health and healthcare in the year 2049. As always, thank you for listening to Health 2049. If you enjoyed what you just heard, please subscribe to us and share this podcast with a friend. Thank you and see you next time.
