Putting the Humanity in Health Care
Relationship-based clinics for older patients set out to upend the system
(Editor's note: This story is part of a series for The John A. Hartford Foundation.)
Bill Craze, 81, of Houston, was frustrated with the doctor he'd been seeing for five years.
"I didn't think I was getting the attention that I needed," Craze says. "I would tell them something that was bothering me, and it wasn't getting addressed. It was like I never said it."
That changed when Craze switched to a clinic that practices "relationship-based" care.
Craze says his new doctor takes the time to sit and listen to what he is saying, "like it should be," he says.
Iora Health, a pioneer of this model, opened its Four Corners clinic in Houston in 2019 — one of 48 relationship-based clinics it operates in 10 states.
Full care is paid for through Medicare Advantage plans, with no supplemental insurance required, making it very affordable. Relationship-based clinics also accept Medicaid, as long as the patient is covered through one of their negotiated Medicare Advantage contracts.
"The thing that heals people is relationship."
A small but growing number of physician-operated, "relationship-based" primary care clinics operated by Iora Health and groups like ChenMed, Oak Street Health and others "are saving money, showing impressive results and reducing avoidable care and risk," says Dr. Marty Makary, a surgical oncologist, professor at Johns Hopkins University and author of The Price We Pay: What Broke American Healthcare — How to Fix It.
When Craze arrived as a patient at Iora Primary Care, he had high blood sugar and was struggling with his weight. After a few months, he was already feeling better. "When I started going there, I felt run down and sluggish. I'm feeling a bunch better now. I'm energetic, I get things done throughout the day."
Craze's doctor reduced the number of medications he was on and assigned him a health coach who is part of the clinic team. Craze's coach, Marisa Perez, checks in with Craze at least once a week. He owes his improved well-being in large part to Perez's encouragement.
Health coaches are fundamental to Iora's approach. Every patient is paired with a coach like Perez who works closely with the doctor and sits in on appointments. Coaches are hired from the community and have strong communication skills. They help patients develop health goals and make sure they understand the necessary follow-up after a visit.
"My role is to help the patients navigate the health care world," explains Perez, who grew up in the Four Corners neighborhood and was trained in sports medicine and rehabilitation. "They talk to me for a bit before they see the doctor. I chat about preventive care, and I'm a shoulder to lean on. They can call me directly; I'm here as an advocate." Perez is part of a close-knit team that huddles every morning to discuss the patients they'll be seeing that day.
"The problem with the health care system is that the cost is not a reflection of our humanity. We have turned health care into a series of transactions," says Dr. Rushika Fernandopulle, a Harvard-trained primary care physician and CEO of the for-profit Iora Health. "The thing that heals people is relationship."
Are Relationship-Based Clinics an Answer to a Broken System?
Unlike "concierge" medical practices that serve a wealthier clientele for a high flat fee, relationship-based clinics often serve highly-vulnerable older people in low-income neighborhoods.
For a flat monthly fee, these clinics provide holistic care aimed at keeping patients healthy and in good spirits — and out of the hospital and emergency room.
"We were lucky to have a supportive, collaborative partner in [health insurer] Humana early on," says Fernandopulle. "Because of our success, other payors have begun to develop a similar strategy. Partnering with multiple different Medicare Advantage plans allows us to care for more patients, which is necessary in order to truly transform health care."
Critics of the American fee-for-service medical system have long complained that doctors are incentivized to see as many patients as possible and to order too many tests and procedures.
"In the typical fee-for-service world, doctors get rewarded for the number of patients they're seeing. See more patients and bill, bill, bill," says Dr. Maina Gatonye, a physician in an underserved area of Miami who works for the relationship-based, for-profit primary care company ChenMed. "In our value-based model, doctors are rewarded based on the outcomes. When patients do well, we do well. Our only driving force is to practice excellence."
According to ChenMed's chief medical officer Dr. Gordon Chen, ChenMed founder Dr. James Chen (Gordon's father) "had to convince somewhat skeptical health plan executives to embrace the idea of paying his medical practice risk-adjusted, per-member, per-month fees for every elderly patient served by ChenMed as a global risk primary care provider."
Now, ChenMed has relationships with more than 20 Medicare Advantage health plans.
While working on his book, Makary visited an Iora clinic in Phoenix. Among the things that impressed him: When he asked to see the billing office, the staff laughed. Because the clinic is paid a lump sum by Medicare Advantage per patient, billing is not required.
For patients, that reduces the money, time and frustration that often accompany a visit to the doctor.
Even more impressive, says Makary, was the clinic's environment. "Most inspiring was seeing the enthusiasm and workplace happiness of the doctors, nurses and care coordinators at these clinics," he says.
Better Health Care at a Lower Cost
Dreaming up ways to better health care for patients is the easy part, says Fernandopulle. What's hard is turning the vision into a sustainable business model.
"How do we both change the delivery model and the payment model simultaneously?" he asks. The counter-intuitive answer is that providing high-quality care is actually less expensive.
Iora negotiates with Medicare Advantage to pay their clinics a higher per patient rate than primary care typical costs. (The amount varies depending on a patient's medical and social conditions, such as living in poverty.) With that amount, the clinics are able to cover specialists and hospital care for patients and still make enough to have a healthy bottom line and pay their physicians good salaries. Iora has decreased hospitalizations by 40% and emergency room visits by 20%, compared to national averages.
"We know exactly who our patients are, and we do whatever it takes," says Fernandopulle. "We never ask, 'Do I get paid for this?' We ask, 'Does this benefit the patient?'" The company encourages providers to be creative, whether that means doing house calls, offering cooking classes for people with diabetes, hosting game nights, paying for transportation to the clinic or providing Silver Sneakers exercise programs and yoga.
Iora finds that by investing in these extras, patients will be healthier in the long run, saving the company significant hospitalization costs.
"I tell her the truth about how I feel, and I trust that I can open up to her."
For Gatonye with ChenMed in Miami, relationship-based care means giving all his patients his cell phone number. "Access to us is key," he says. The average ChenMed patient is 72, with five chronic conditions and living within 300% of the poverty level. Physicians see their patients at least monthly, focusing on one or two problems at a time.
According to ChenMed spokesperson James Brown, most patients just come to the clinic if they're not feeling well, since walk-in appointments are welcome. Like conventional clinics, physicians also take turns being on call. The small patient load allows doctors to be more generous with their time, Brown adds.
According to ChenMed, its doctors care for one-fifth the number of patients as do their fee-for-service peers — 400, compared to more than 2,000. As a result, ChenMed doctors are able to annually spend 10 times the amount of "face time" with patients, compared to typical fee-for-service practices.
A study by ChenMed and University of Miami researchers in the peer-reviewed American Journal of Managed Care found that "high-touch" primary care clinics saw their patients more frequently than standard clinics, yet the average monthly cost was $87 compared to $121. The number of hospital visits was cut in half, too.
Rev. Oscar Taylor, 74, a patient at a ChenMed clinic in North Miami, is a good example of the benefits of relationship-based clinics. A former longshoreman, he had to stop working due to arthritis and back trouble. Before he signed up with ChenMed, Taylor was constantly in and out of the hospital, admitted more than 30 times for heart problems and other ailments.
Since seeing Dr. Hermena Cerphy at ChenMed, "I haven't been hospitalized, and I haven't been sick," he says. "When I get there, Dr. Cerphy will ask me various things about my body, my feelings. It might not make sense to me, but it makes sense to her. I tell her the truth about how I feel, and I trust that I can open up to her." He recruits friends and fellow congregants to come to ChenMed.
So does his ChenMed care-promoter (what the company calls its medical assistants), Guerline Jeudy-Phaurestal. She loves her job, and has recruited her sister to work there. Her father is a patient, and she's hoping to get her other sister a job there, too.
Jeudy-Phaurestal gives her personal cell phone number to her patients. On a recent day, she offered to give two patients a lift home on her lunch break, after seeing they had been waiting a long time for a driver to come.
This kind of commitment to patients pays off for relationship-based clinics, which often depend on word of mouth to spread the word. ChenMed has grown from one small clinic in Miami to what will be nearly 80 in 10 states by mid-2020. Iora's patient numbers have grown 60% annually, according to Fernandopulle.
But the numbers are small compared to the entrenched fee-for-service model with which they are competing.
If the relationship-based model were to become the norm, the nation's Medicare patients would be much better off, Gatonye says. "They'd be healthier, with better outcomes, fewer strokes and heart attacks, and their families more at ease," he says. "We'd be doing all of this at much lower cost. If we extrapolate the savings, it's huge numbers."