America’s primary care revolutionaries

Jacob West reflects on some his experiences of innovation in America's primary care providers.

Blog post

Published: 16/12/2014

A new breed of healthcare provider is subverting the model of American healthcare for its most needy patients, whilst improving care and reducing costs.

Need a lift to the doctor? If you’re a patient of CareMore in the American southwest, they may well chauffeur you there. Worried about falling over in your sitting room? They’ll fit you a new carpet. Not sure when to pop your next pill? Don’t worry – your medicine box will sing you a tune when the time comes.

Casual observers might not expect to see this kind of practice in the hard-nosed world of US healthcare. And to be sure, this is not the norm. Yet.

But a new breed of primary care provider, such as CareMoreChenMedIora Health and HealthCare Partners are creating a quiet revolution.

A focused approach

The core market for these new providers is primarily older people and those with the greatest need and highest costs (the ten per cent of patients who account for around two thirds of spending

Their approach is team-based, high-touch, preventative primary care supported by attentiveness to detail and great data. The goal? To keep people well and avoid hospital if at all possible. “What’s more costly, a $50 car ride or a hospital visit?” asks CareMore’s President Jason Mancuso.

Health policy wonks looking across the pond for guidance on primary care would have been scoffed at until recently. It wasn’t that long ago that the death of primary care in the US was being predicted. Even now, levels of morale, pay and staffing are still low.

But these new ‘Hot Spotters’, as Atul Gawande has dubbed them, along with a parallel trend of direct access primary care, mean that it’s time to sit up and take notice.

The splendidly named Rushika Fernandopulle uses an historical parallel to explain the approach of his company, Iora Health. Small-thinkers in the early 1900s were scratching their heads about how to improve the speed of transatlantic ship crossings. Big-thinkers like the Wright brothers invented the airplane.

Iora Health is thinking big. Having cut his teeth by developing his model within existing high performing systems like Virginia Mason, Fernandopulle has been developing primary care clinics from scratch.

Central to the Iora approach is a fundamentally new kind of care model. Everybody gets a health coach. After every meeting, patients get a call to check in. Email and 24/7 phone access to doctors are ubiquitous. When hospital care is needed, it is ‘co-managed’ with carefully selected specialist doctors. Coupled with a capitated payment and a home-grown IT system, Iora are looking to turn healthcare upside down.

CareMore’s approach has some parallels. The focus is on the 20 per cent who drive the largest proportion of costs. At its heart is the CareMore Care Center, staffed by a mixed team of primary care physicians, nurses, mental health and social workers. For those who need them,'extensivists' help coordinate the link with specialist care.

Do these models work?

Apparently, these models of care are working remarkably well: fewer hospitalisations, shorter stays, lower readmission rates, and happy patients and doctors.

A few examples: Iora’s program in Atlantic City improved blood pressure and blood sugar control. ChenMed’s Miami clinics score in the top third of all local practices on clinical outcomes. HealthCare Partners patients stay at hospital for just over three days; most people in the US stay about six. CareMore’s 30-day readmission rate is around 12 per cent - the national average is closer to 20 per cent.

And it saves money. CareMore’s overall member costs are about 18 per cent below the Medicare average. Iora’s model helped save Boeing around 20 per cent.

Taking it to scale

The easy comeback for sceptics used to be “can you scale it?” It’s still the right question. But the answer has changed. What was once a cottage industry is now looking disarmingly mainstream – and attractive to investors.

Take HealthCare Partners: 20 years ago three practices came together in Los Angeles. It’s now one of the largest medical practices in the U.S. The year before last, the dialysis giant DaVita bought it for over four billion dollars.

CareMore, meanwhile, was bought by the insurance giant WellPoint in 2011 and now serves over 70,000 patients across Arizona, California and Nevada. Iora now has centres across six U.S. states – from Las Vegas to rural New Hampshire.

Let’s not get carried away. This is working despite the U.S. system, not because of it. In a healthcare system that is dominated by powerful hospital interests and where you still get paid for doing more rather than better, there will be limits to how far these revolutionaries can travel.

What lessons for the UK?

While the NHS has a far stronger tradition of primary care than the US, this shouldn’t mean it closes its eyes to models of this kind. This isn’t about copying and pasting a big new idea.

Many of our GPs are brilliant entrepreneurs in their own right. Organisations like the Hurley Group, Vitality and many others demonstrate how this can start to be done with a larger population.

But we tend to make a couple of mistakes. Too often the NHS has confused its universal offer with one way of doing things for all patients. At the same time, we struggle to replicate and scale good ideas.

Maybe this is changing. The recent NHS Forward View (overseen by a man who knows a bit about US healthcare) may have opened the gate. It explicitly calls for ‘multi-specialty community providers’ to emerge from primary care. Let’s hope primary care takes on this challenge. We need them to develop scalable models that find new ways of working with hospitals and technology; that can be targeted to different patient groups; and that can improve quality and bend the cost curve.

So even if England has historically had a distaste for revolution (whether at home or abroad), let’s show we can occasionally make an exception.

Jacob West was  Harkness Fellow at the Harvard School of Public Health for 2014/15. 

Suggested citation

West J (2014) ‘America’s primary care revolutionaries’. Nuffield Trust comment, 16 December 2014. https://www.nuffieldtrust.org.uk/news-item/america-s-primary-care-revolutionaries

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