Payers are getting onboard. A range of recent pilot programs modeled on Iora’s — by Aetna, CareMore, Dignity Health, Humana, Kaiser Permanente, and the Medicare Advantage program — are using coaches and home visits to substantially improve health and lower costs. One study found that providers participating in Medicare’s Independence at Home Demonstration saved $1,010 per beneficiary on average in the second year of the program, primarily by reducing hospital use.
The Innovation Health Care Really Needs: Help People Manage Their Own Health
This shift is long overdue. Whereas new technologies, competitors, and business models have made products and services more affordable and accessible in media, finance, retail, and other sectors, U.S. health care keeps getting costlier. It is now by far the world’s most expensive system per capita, about twice that of the UK, Canada, and Australia, with chronic conditions such as diabetes and heart disease now accounting for more than 80% of total spending.
These astronomical costs are largely due to the way competition works in American health care. Employers and insurance companies — not end consumers — call the shots on what kind of care they will pay for. Large hospitals and physician practices, in turn, compete as if they’re in an arms race to attract payers, adding advanced diagnostic gear or new surgical wings to differentiate, driving up costs.
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In most industries, disruption comes from startups. Yet almost all health care innovation funded since 2000 has been for sustaining the industry’s business model rather than disrupting it. Our analysis of Pitchbook Data shows that more than $200 billion has been poured into health care venture capital, mostly in biotech, pharma, and devices where advances typically make health care more sophisticated — and expensive. Less than 1% of those investments have focused on helping consumers to play a more active role in managing their own health, an area ripe for disruptive approaches.
The Whole-Person Approach
One big incumbent that has become more receptive to disruptive innovation is the insurance giant Humana. It has partnered with Boston-based startup Iora Health. Created by physician-entrepreneur Rushika Fernandopulle, Iora has advanced a disruptive primary-care model that uses relatively inexpensive, nonphysician health coaches to identify patients’ unhealthy habits and life styles and guide them toward better choices, before health problems arise or become serious. Since its founding in 2010, Iora has attracted more than $123 million in funding and now operates 37 practices serving 40,000 patients in 11 states. Iora trains health coaches to become the consumer’s advocate, acting as the quarterback of an extended care team that includes a physician. When visiting an Iora clinic, the patient meets with the coach to establish a health agenda before seeing the doctor. After the patient sees the physician, the health coach and patient debrief to ensure the patient can confidently pursue the agreed-upon health goals — for example, by adopting new health habits. The coach then serves as the patient’s connection with the Iora team, and creates accountability.
Another feature of the Iora model is the morning huddle, when the entire care team invests an hour discussing the health status of the clinic’s population. Because Iora assumes full financial risk for its patients — it is payed a set fee per patient for a given period — the huddle prioritizes those who require the most attention and directs care around their needs.
To that end, Iora has developed a “worry score” methodology, which rates each patient on a 1-to-4 scale according to their health status and needs. Patients scoring a 4 require a specific action, such as immediate outreach from a health coach. If the patient’s outlook turns for the better, their worry score is lowered, a development celebrated by the team.