Is Scalability Overrated?

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Scalability is the end goal of nearly every tech start-up, systems innovation, and teenager you-tubing their cat – it’s going viral, business-style. And traditionally, it’s been seen as a marker of relevance and success. Growth is good, right?

But in healthcare systems transformation, do we lose something meaningful when we measure the value of our work by its national impact?

Take Iora Health, a new healthcare venture out of Massachusetts that contracts with large companies and insurance plans to provide care for employees or insured patients. Iora clinics have a for-profit model and are seeking to capitalize on saving money. They charge companies and insurance plans monthly fees and in turn endeavor to keep their patients out of hospitals and emergency rooms, the most expensive places to receive care. If they successfully prevent costly services, and save their company or insurance plan money, they take a percentage of those savings as profit.

The Iora model is essentially beefed up the primary care services offered in the comfort of a patient’s community, sometimes even as convenient as a local shopping center. They argue that by providing health coaches, lower doctor-to-patient ratios, around-the-clock availability, excellent customer service, and unlimited visits per patients, they can effectively manage most chronic illness before it progresses and requires hospitalization or emergency services. Now, nothing they are offering is particularly new, as primary care practices across the country are considering or implementing similar strategies. But what is intriguing, is their plan for growth.

As The New York Times recently wrote, Iora’s “ultimate goal is hundreds of practices across the country, a kind of Starbucks for healthcare.” And as their CEO Dr. Rushika Fernandopulle stated, “Building one good practice is mildly interesting, because a few people have done that. But how do you scale that across the country? That’s much harder.”

Hard, yes. But meaningful, I’m not so sure.

See, Iora’s foundation is venture capital and their business model aims to create a revenue stream providing services most clinics cannot afford; because most financial incentives in healthcare favor hospital and emergency visits. On the surface, it’s a win for doctors because many physicians want to provide comprehensive care, and it’s a win for patients, because Iora is paying to provide a care experience consumers want. But what about low-income populations? They lose here.

To maintain the for-profit status that supports their model, Iora Health purposefully doesn’t take patients off the street, the uninsured, or the unemployed for that matter, I guess unless some unemployed individuals are buying insurance with a plan they contract with. And yet, Iora says their model is going to “transform healthcare” and scale across the US.

When 5.5% of the population is unemployed and more than 1 in 7 live below the poverty line, how is this model “transforming” the system for everyone? The truth is, it’s not.

So I return to my initial question, do we lose something meaningful when we measure the value of our work by its national impact?

In Iora’s case, as with many clever and highly specialized health systems innovations, I think we do. Iora’s business model is what drives their innovation, but it is also what makes their services irrelevant in populations that don’t qualify or need their comprehensive care. It doesn’t make what they are doing any less valuable, but it does mean they may not find significance with every population. In addition, since their model excludes populations already under-served by the healthcare system, their national dissemination may actually threaten access to care for low-income families.

Healthcare is a complicated enterprise where the needs of the consumer are variable and evolve overtime. That diversity of need and resource distribution defines the challenge in our current system. And in the end, that variability may be too complex for a one-size-fits-all, Starbucks model.

Perhaps healthcare doesn’t need cookie cutter solutions imposed on populations with distinct assets and needs. Perhaps just like politics, all healthcare transformation is local and finds meaning in its local application, not its national prominence.

We all know ideas with traction and those that find their way to a national stage are exciting. But I think there is something to be said for offering a unique service to a distinct population, and doing that well for the long-term. So instead of looking for the next big thing, the actual big thing is made up of small things that are changing the way each of us experience our healthcare.

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Walking the Talk

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I’m back!

After a 3 month hiatus from writing, I’m back! And although things went radio silent on my blog, I’ve been busy working on projects that I am excited to share with you guys! But first, let me tell you why I took a break.

For those of us who think critically about the delicate social safety net that is fraying under mounting pressures of growing inequality and finite public resources, it is clear that more than thoughtful rhetoric is required to bear this heavy load. It is also clear that there are new opportunities for the healthcare industry to unite with the social sector to address the most egregious impacts of poverty in our society – death and disease. So while I took some time away from talking the talk on here, it is in part because I found new opportunities to walk this walk in my professional life.

Now, I’m back, and with new experiences that will hopefully inform our conversation on this blog. So look forward to new posts as I continue to think about the intersections of race, gender, social inequity, structural inequality and health in our society and ponder aloud how we might address these issues together, through our unique work.

Here are the questions that will drive my next posts:

1. Is worse care better than no care? Do new models of care trialed by pharmacies (think CVS, Walgreen’s) and internet giants (think Google and Facebook) suggest access is more important than quality? How should what we know about quality drive how we provide care across the medical infrastructure?

2. How can technology bridge the gap between the healthcare and social sectors, as we both endeavor to address the impacts of poverty on society? This question is intimately related to a question I frequently ask on this blog: If patients bring doctors their social needs and doctors know those needs impact their health, what is the physician’s role in addressing social needs?

3. Cultural Competence vs Cultural Consciousness. What is the correct framework for understanding and addressing health disparities? How should we teach physicians and trainees to engage their unconscious bias in clinical encounters such that all patients receive and perceive quality care, regardless of their “cultural” background?

Okay, those are a few teasers to tide you over for now 😉 And if you have other topics you’d like me to address, please leave a comment and I will do my best to include them in upcoming pieces. Looking forward to walking the talk together!

Until then, be well!

Rhea

What an Oreo can Ad to Medicine

OreoHow do you prepare for something that doesn’t exist?

In medicine, what tools will be required to build a better future for providers, patients, and the many advocates who work to make health realized?

Like our predecessors before us, embracing an unknown future will likely require solutions that are part rigorous methodology and part instinctual art. I am confident that the rigorous methodology that makes science unique among fields of scholarship will continue to advance discovery in health and disease management. But how can modern-day physicians and health advocates use the art of our practice to increase health literacy, connect the dots between health and society, and optimize our relationships with complementary fields?

When I saw the Oreo Super Bowl ad, I knew. This is what medicine should be doing. Not pushing sugar sweetened products, but utilizing moments to capture national attention around a singular idea – health.

For those of us interested in the exciting opportunities new technology offers the field of medicine, Oreo taught us that capturing national attention may be as simple as fostering thoughtful application of new media; media that for all said purposes, is free (although the thoughtful application part definitely requires a significant investment…more on that in future posts).

It is clear that consumers are now making decisions in the context of an online network of peers where they collectively share cultural experiences and discuss trending topics in news and popular media. This is an incredible opportunity to key into consumers who are looking for health information, information that data suggests some are using to make health decisions. Interacting with patients on their timetable, moderated by their thoughts and comments, and based on their personal priorities, allows medicine to have a greater impact beyond the confines of our offices and medical centers. And I’m not just talking about e-visits (although this is an interesting and potentially great idea), I’m talking about engaging a national audience in a conversation about health, identifying partners in this work, and aligning all of our interests to reach a common goal – health.

Part of preparation for any unknown outcome is recognizing opportunities to take steps in the right direction. New technology, like that promoted by incubators like Rock Health and thought leaders like Wendy Sue Swanson, MD and Bryan Vartabedian, MD, will definitely define the future of our field; a future that I hope is rooted in simplicity, transparency, and good old customer service.

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