HL20: Rushika Fernandopulle, MD—Hitting the Reset Button on Primary Care

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Rushika Fernandopulle, MD.

This profile was published in the December, 2014 issue of HealthLeaders magazine.

"One of the rules is we do not bill fee-for-service, period. Big period at the end of that sentence."

As hospitals, health systems, and insurers tinker with payment models that preserve the current fee-for-service reimbursement while preparing for a fee-for-value environment, Rushika Fernandopulle, MD, cofounder and CEO of Cambridge, Massachusetts–based Iora Health, is moving forward with his vision for primary care that puts payment last and patients first.

"Trying to do the right thing for primary care when you're getting paid the wrong way is really hard, if not impossible," says Fernandopulle. His company, Iora Health, works directly with self-insured employers, unions, and health plans to open primary care clinics that do not take patient copays and do not bill fee-for-service. In two years' time, Iora has opened a dozen of these global-payment-only primary care clinics across the country.

Fernandopulle says the company's rapid growth is because self-funded employers who are on the hook for all of their workers' healthcare costs are looking for ways to save money. Iora offers that with a simple demand: Pay a global fee for patients and let us do what we need to do to get and keep them healthy. Recently, insurance companies have been calling, too.

Like many primary care physicians, Fernandopulle bemoans the fee-for-service payment model, saying it gives doctors a perverse incentive to overtreat, overdiagnose, and overlook the root of patients' problems. "All you get paid for are sick visits, and many of the things that are the right thing to do for patients are not doctor sick visits," he says.

Health plans are rolling out accountable care organizations and other shared-savings programs that attempt to give physicians more freedom to take care of patients, but those projects are not widespread. Fernandopulle also says sustaining two payment models is untenable. "What happens in a typical practice is that you might have a few contracts where you can convince people to pay you differently, but the rest of your patients are still being paid for the old way," he says, recounting this exact experience with an early pilot project at a practice in Seattle.

Fernandopulle says the practice ended up having to color-code charts to discern which patients belonged to the plan that paid for value and which didn't. The irony was that the patients had the same needs regardless of their plan, but doctors couldn't take care of them the same way; in a fee-for-service model, if the cost is lower, so is the doctors' income. Fernandopulle also says the administrative burden of managing two systems was overwhelming. "Doing two different things in the same practice … that's just an unholy mess."

So Fernandopulle stopped trying to work with the system. Instead, he does whatever it takes to keep his patients happy and healthy. And he says the data is bearing out his vision.

"Our patient satisfaction is through the roof," says Fernandopulle, who uses Net Promoter Score to measure patient experience and satisfaction. The NPS measurement system has typically been used to measure customer loyalty for retail organizations, but health systems have begun adopting it, too. "Our NPS score is in the 90% range. That's higher than Amazon, Whole Foods, and Trader Joe's. And our outcomes are not a little better, but hugely better. Our practices' impact on downstream spending shows a 50% drop in ER visits and a 12%–15% drop in total spending."

And while Fernandopulle rails against electronic health records and CPT codes, because he believes they exist to help payers and not patients, he acknowledges that in order for his vision to become a mainstream reality, he has to get cooperation from health insurers. Of course, they'll have to play by his rules. "One of the rules is we do not bill fee-for-service, period. Big period at the end of that sentence," he says. "We will not submit codes. Why do they need the codes? Who cares how many visits we do, or how we get there? What they should care about are the outcomes. How we get there is irrelevant."

There are visionaries in healthcare, many of whom are included in this HealthLeaders 20 list, but Fernandopulle is outside of the mainstream, not constraining himself to the existing relationships among patients, doctors, hospitals, and payers. He is building what he believes is a new "operating system" for healthcare, and he's hitting the reset button.