Reimagining the U.S. healthcare system

Teresa Chahine: Welcome back, everyone. I’m here with Peter Hagan, the Digital Health Director of Commonwealth Care Alliance, and he’s here to talk to us about his former role in Iora Health, which was one of the startups that really pioneered the value-based care model in public health. Thank you so much, Pete, for being here with us today.

Peter Hagan: Thank you for having me.

Teresa Chahine: You’re able to speak to value-based care and to the Iora case in a way that no one else is because you started out as a patient and then became a health coach and then became a product developer. So you’ve played so many different roles within Iora. Can you start by telling us, for those who don’t know, what is the concept of Iora? And then we’ll dig into those three roles that you played.

Peter Hagan: Yeah, absolutely. So I think the best way to introduce Iora is really to just share the mission, which is to restore humanity to healthcare, which I think just resonated for a lot of people who have had more traditional typical healthcare experiences of sitting on a cold bench and not having terribly friendly service when you’re in any type of healthcare setting.

Teresa Chahine: Yeah. No one wants to go get healthcare.

Peter Hagan: Exactly. And it’s always shocked me that that’s been the case for healthcare because of all industries, this is really the one that needs to deliver with empathy and with respect toward patients who are often in difficult situations or even crises. Being there for them is a top priority, and I think that the service standard often is just lacking, not across the board with healthcare, but too often I think that’s the experience of a lot of patients in healthcare.

And so the core mission of Iora is really to address that and start from the ground up, start from scratch with the technology, the people, the processes behind a strong primary care model and start with primary care because that’s an area where the U.S. arguably has underinvested at the expense of a lot of downstream costs from procedures and testing and other sources of healthcare expense that often flows downstream from what might be a weaker primary care relationship upfront. So Iora is really focused on investing in that primary care relationship and with the bet that that will pay dividends down the road for patients and allow us to demonstrate better health outcomes at lower cost, which is always the million-dollar question.

Teresa Chahine: Yeah, exactly. So to frame this for our listeners who are less familiar with the health sector, this course is about public health entrepreneurship, and it’s really centered on health equity, can everyone have an equal opportunity to realize their full health potential? And I start off the course by talking about drivers of health, the social and environmental factors that really drive the majority of health outcomes. It’s said that 70% or more of health outcomes are really because of factors like nutrition, housing, utilities, energy, child care, all these things, education rather than healthcare services. And yet in this country, the healthcare sector is mostly driven on healthcare services, not on providing health. So people make money in the health sector by providing services, not by providing health. So that’s the key distinction I think that Iora and others like them are trying to create, is that we want to shift to a system where providers and payers and patients are incentivized to focus on health, not healthcare services.

And it doesn’t sound like it is something that would require innovation. It sounds like, shouldn’t this be the obvious thing? But that’s not the world we live in the U.S. And I know that Iora is not the first to test this. So Kaiser I think is the oldest maybe value-based care organization focusing mostly in the Northwest or the West Coast of the U.S. And it seems that it’s just that it hasn’t been able to spread because the fee-for-service model is so deeply entrenched. So that’s why I think Iora Health is so interesting to talk about, and I know that now it doesn’t exist anymore. It was acquired by One Medical, which was later acquired by Amazon. So we have a lot to discuss in terms of how it has evolved.

So let’s start at the beginning, now that we have that background. When Iora first launched as a startup, it had to do a few pilot tests in certain areas to just demonstrate, “Are we able to use this team-based approach to focus on a lot of people, not just a medical doctor, helping a patient to be healthy and lower costs in that way?” So one of the pilot sites to test this proof of concept was Dartmouth University. And at the time, you were a fellow there working in the President’s Office. Right? So you started off as a patient of Iora Health. So what was that like?

Peter Hagan: Yeah, so it was really an impactful experience. It led me on a journey of five years with Iora thereafter. And so I think the feeling that I got when I entered into an Iora practice was just one of almost just an intuitive knowledge that this is really more like what healthcare should be. Compared against every interaction that I’d had with the healthcare system to that point, this was a place where they were being transparent. They were showing me my record on a screen for me to participate in.

Teresa Chahine: I’ve never experienced that. Usually, the provider is looking at the record and I have no idea what they’re looking at.

Peter Hagan: Right. I’d like to think that that concept has taken hold a little bit more. Iora did it as a standard of care with all their visits, but I believe there are other providers now that are starting to adopt that type of principle with using technology to make patients active participants in their healthcare. And sometimes patients even catch things when things are transparent that, “No. Actually, it was this condition that I was diagnosed with 10 years ago.”

So I was really impressed by that, and it felt like a very respectful experience for me to be able to engage with my care team in that regard. And my care team looked different than it did from other doctors’ offices that I had been to previously where it might be someone who’s in a rather hurried fashion just quickly coming in, checking vitals before you even really have a chance to sit down and relax, so your blood pressure’s likely a little higher.

Teresa Chahine: They’re already thinking what’s their conclusion going to be in their notes and head out to the next patient.

Peter Hagan: Right. They’re onto the documentation and not necessarily there and present with you as the patient and there to hear you out and hear your concerns. There’s a stat, I believe it’s something like 11 or 17 seconds before a patient is interrupted typically—

Teresa Chahine: Wow.

Peter Hagan: ...during the course of their medical encounters. That’s just an average. There’s time tracking done on that, and it’s just a matter of seconds before the member—or the patient, rather—can really express what’s going on with them and be clear about what they’d like to tackle for an agenda for that visit.

Teresa Chahine: And providers don’t want this, either. We were just chatting after class.

Peter Hagan: Right.

Teresa Chahine: It’s like they don’t spend years of their lives training in medicine to... they want to be able to work more with the patients. It’s just, the system is not set up in that way.

Peter Hagan: That’s right. Yeah. So I think that was really the bet for Iora, that “Let’s make this more relationship-based and foster that trust upfront so that someone can feel like they can go to us if they are in crisis later or if they have an issue and also show them all that we can take on in a primary care setting,” because I think too often, when I worked at Iora later, I crack up because a patient was at the ENT—ear, nose, and throat doctor—and called me up and saying, “Hey, I need a referral. I’m about to get my ears cleaned at the ENT.” And that was a specialist visit that is a very, very doable visit in a primary care setting. So a lot of that was about optimizing and—

Teresa Chahine: They were still thinking—

Peter Hagan: Right. Right.

Teresa Chahine: ...and the whole setting.

Peter Hagan: Just making the most of what can be done in a more one-stop shop fashion in a primary care setting. So that was another learning that I had as a patient, just that, “Wow, there’s a lot that I can go to this office for, versus needing to use the full healthcare ecosystem.” And then the last part that I really enjoyed was just forming a connection with my health coach in that setting who followed up with me after the visit and provided detailed notes on what we had discussed during the visit with clear items for me to follow up on and some personal touches involved as well. We had a chat about nutrition, and he said, “Hey, by the way, I just want to give you some more information that Forks Over Knives Diet that we had talked about.”

Teresa Chahine: Like plant-based.

Peter Hagan: Yeah, plant-based diet. And it impressed me that nutrition was a topic that I had never really had a chance to have a discussion about in any type of medical setting up to that point. Which again, is—

Teresa Chahine: I think today, one of the students in class who practiced medicine—

Peter Hagan: That’s right.

Teresa Chahine: ...for decades shared that he only studied nutrition for four hours in his entire medical training.

Peter Hagan: That’s right.

Teresa Chahine: And that was decades ago.

Peter Hagan: That’s right.

Teresa Chahine: So I think the health coach brings up a really important part of the Iora model, which is that it’s a team that’s responsible for keeping the patient healthy, and you don’t actually have to spend all the time with the medical doctor, but there are others there to talk about those drivers of health.

Peter Hagan: That’s right. And as long as you’re doing it within the bounds of whatever that health coach is licensed to do, obviously the diagnosing and the treatment plans are still ultimately left to the provider. And I think that’s sometimes a misconception about models like the one that Iora pioneered, which is that, “Oh, I’m not going to get to see a doctor anymore.”

Teresa Chahine: Yeah. You still get a doctor. Yeah.

Peter Hagan: That’s right. They’re very much a part of the care team, but it’s also about just recognizing that there’s a flavor of needs that patients often come to a doctor’s office with that maybe can be managed through someone who has more of the background of a health coach who does have some expertise with things like nutrition or movement or meditation and stress management. And those are all important drivers that are behind our pillars of health that are just too often shortchanged in traditional healthcare settings, and I think it’s a key value-add of this healthcare concept for Iora.

Teresa Chahine: And that’s a great segue. So you started off as a patient, and then you became a health coach yourself. Tell us about that.

Peter Hagan: That’s right. Yeah. So I was on this track to pursue medical school, and I really was craving more of a healthcare delivery experience before I jumped ahead to a ton of schooling and research and working in things that I felt weren’t really directly tied to that end experience that I was after. And so was able to fast-track that a bit by doing EMT, emergency medical technician training in Manhattan. And at the time that I was doing that training, I was still in touch with my health coach from Iora.

Teresa Chahine: Oh, wow.

Peter Hagan: He mentioned, “Hey, Iora is hiring in Manhattan.”

Teresa Chahine: Oh, wow.

Peter Hagan: And just a fortuitous development. And I ended up applying to Iora to work as a health coach, which felt like an even more direct exposure to “What is it like to deliver healthcare in a primary care setting?”

Teresa Chahine: Or to deliver health, really.

Peter Hagan: To deliver health. Right. I think I was very much in the business of helping people with their health and not exactly being tied to—

Teresa Chahine: Services.

Peter Hagan: ...traditional healthcare services that you mentioned, but thinking outside the box about how can we actually move the needle in this patient’s overall feelings of health and feelings of well-being?

Teresa Chahine: One of the things that really struck me about the Iora case was how they hire coaches, and it’s less about the qualifications you have on paper. You don’t necessarily train for it. Maybe Iora trains you a little, but it’s more about... I think they called it in the case, “the hug factor.” When a person walks in, do you connect with them as a person? And you were talking about empathy, and that’s really the main thing they’re looking for, right?

Peter Hagan: That’s right. Yeah. Empathy is something from my experience that’s much harder to train on. It can be somewhat of an uphill challenge. If you hired somebody who has all the right technical skills and maybe is skilled in phlebotomy blood draws and can do vaccinations, and that’s all well and good, but do they have that personal factor and that ability to connect with patients and hear them out, just be an ear for them to speak with and in whatever interaction that patient is having across their health visit?

Iora I think was very much focused on hiring for empathy and making that just consistent across whatever person that the patient was engaging with. Having a caring team who really has those extra supports in place to make the patients feel like they’re listened to and to start fostering the trust that’s required upfront to then ensure that that same person can feel like they can come back to this care team and go to them for any needs that may come up and be that first line of defense for whatever the patient might be going through.

Teresa Chahine: So we talked about, for the value-based care model to work, you need this team-based approach where you’re held responsible for the patient’s long-term health outcomes rather than for providing specific services. One thing we haven’t mentioned yet, for listeners who aren’t familiar with it, is a lot of that is related to the payment mechanism. Usually, providers get paid for providing services, not for providing health. And so some of the payment methods for value-based care are different. For example, you get paid in a capitation model, am I using the word correctly?

Peter Hagan: That’s right.

Teresa Chahine: Per person.

Peter Hagan: That’s right.

Teresa Chahine: And then you keep the change when you save costs by helping them be healthy and need less services. And so I think another thing that came up in our discussions today in class was the role of technology, both in tracking data on patient health outcomes and freeing up time for the team to spend with the patient, rather than admin, and also potentially finding ways to lower costs. And I know that Iora developed its own electronic health records system, which really helped enable its model to work. And if I understand correctly, you later went on from being a health coach to working at their headquarters in Boston where you worked on product development and you worked in the technology. So share with us a little bit about that?

Peter Hagan: Yeah, absolutely. So I loved my time as a health coach, still my favorite job, as I shared earlier, but I was also really motivated by the potential for technology to be a game-changer with regard to positively influencing patients’ experience and also helping to route the resources where they’re needed most. And so we did things at Iora like showing the patients’ record to them on a screen with a very friendly interface that patients could understand that didn’t have a lot of medical jargon on it.

Teresa Chahine: You mentioned it’s kind of like a Facebook profile. It’s like a really patient-centered interface—

Peter Hagan: Right.

Teresa Chahine: ...which I’ve never experienced. I’ve always thought it was for the providers, and it was like a backend thing, but the patient is a core part of the team.

Peter Hagan: That’s right. That’s right. Yeah. And that was an ambitious part of Iora’s model in the sense that it is expensive to build technology—

Teresa Chahine: Right.

Peter Hagan: ...and hiring a whole team, a product team with software engineers is a big investment. But there was a firm belief there that we needed to start from scratch and not be reliant on—

Teresa Chahine: In order to lower costs in the long run and improve outcomes.

Peter Hagan: Exactly, exactly. Yeah. So I would say when I was at Iora, we had things like a... we called it a worry score, which was kind of a population health type metric of how concerned are we for any given patient: high, medium or low? And at the start, at least, it was a much more subjective measure that was driven really by care teams having a pulse on how each member is doing. And this is a case where technology can only be so helpful in surfacing what next best action might be taken by the care team or by the patient. But the key part that I think Iora got right was using tools like that to drive processes like our morning huddle where we would check in on some of those highest-risk patients first and make sure that they were top of mind because it can be gratifying to work with other patients who might have a lower disease burden and not necessarily require as much attention from a medical and health standpoint but are still fun to work with.

And so the challenge can be outreaching and getting clear on what the data is showing in terms of which of those patients really are going to benefit most from an intervention right now. So I am optimistic that there’s a bright future for using more analytics and A.I. to really help health plans and health providers understand who are those patients who really need support and what are the most effective interventions for their cases? And so I think there’s a long ways to go, but we did some exciting things to get started on that when I was at Iora.

Teresa Chahine: It sounds like even though the value-based care model that Iora is pioneering was really dependent on being high-touch—like human touch—model, this needed to be enabled by the technology, otherwise it wouldn’t be scalable. And after leaving Iora, you continued to work on that aspect as the Digital Health Director in your current organization. So looking at the case of Iora from the outside, now having some distance from it, and on the topic of scale, Iora I think eventually scaled by being acquired by a primary care group that was operating nationally called One Medical that adopted their value-based care model and focused on preventative care. And then maybe a year or so ago, One Medical was acquired by Amazon. And so now I find myself wondering, and I’d love to hear your thoughts, is Amazon really applying this high-touch model that you are part of as a health coach and a patient? To what degree, I would say? It’s not a yes or no.

And also, going back to health equity, which is the focus of this course and of your visit today in terms of having each person have equal opportunity to fulfill their health potential, is that Amazon’s goal? Is it focused on health equity? So on my end, I’m feeling a bit worried. My worry factor, speaking of worry score, my worry score is high because Amazon I think has the ability to scale the technology, the data, lower costs, allocate resources. I’m just not sure how invested they are in that human factor. What are your thoughts on the degree to which this model is scalable and the role of players like Amazon?

Peter Hagan: It’s a great question. A hardball question from you.

Teresa Chahine: I know. It’s...

Peter Hagan: Yeah, no, it’s a great one though. Very interesting developments over the last couple of years with Iora.

Teresa Chahine: And just speak as a digital health provider, but also as a patient and parent.

Peter Hagan: Sure, sure. Yeah. So know thy patient and know thy population is an important principle. I think we were always taught at Iora that healthcare is heavily localized, and it varies from place to place and person to person. And so that factor is a key one that for a giant like Amazon to get right and to personalize, I think, would be a pretty tremendous challenge. What I would say is that what do people go to for Amazon now? I think they appreciate having something at the right price at the right time, and the convenience factor is really there with Amazon. And so I do think there’s likely a role to be played just in terms of making some aspects of healthcare more convenient for the general population, perhaps breaking down some access barriers where some patients cannot get seen by the right specialist for many, many months.

Or there’s something simple that brick-and-mortar healthcare experience is not really equipped, like, “Hey, I need this refill and people need to contact five different numbers to get that approved.” So there might be some opportunities for them to bring some of that Amazon spirit towards solving some of those thorny problems that have resulted in subpar consumer experiences in healthcare. But I would absolutely agree with you that I would share that concern that some of the original DNA of Iora where we were really able to meet patients where they’re at and customize and personalize their experience and build trust and build the relationship, that’s very much an open question in a model like Amazon’s.

I hope there will be a commitment to that. I have to hope that that’s where they’ll eventually be able to figure out, “This is how we’re actually going to influence healthcare outcomes and eventually reduce costs,” because that’s the goal at the end of all of this. U.S. healthcare just ballooning in size and is a huge expense that has tons of implications for our country. And so Amazon has been at this for a few years now and tried a couple of different pilots and ultimately landed on this acquisition of One Medical and Iora, which I hope the nature—

Teresa Chahine: They’ve tried a few things in the past that just didn’t work.

Peter Hagan: That’s right. That’s right. But my hope is that that’s a sign of perhaps what Amazon is committed to, understanding that Iora and One Medical bring a certain flavor of more high-touch healthcare experiences that can be personalized. But yeah, it’s very much an open question. I think it’s an unknown for me right now where that model will go, given that Amazon is really at the helm to steer this ship.

Teresa Chahine: Here’s my take on it, and then I want to hear your thoughts on my take.

Peter Hagan: Sure.

Teresa Chahine: I want to give you the last word, but I think that when you were speaking in class today, I had this moment of clarity literally in the last minute of class that the question I’ve been asking my students for almost a decade when I teach the Iora case is what will it take for this model to be adopted by the existing players in the healthcare system who are not really incentivized to provide health but rather healthcare services? How can we switch as a nation from being largely fee-for-service to be largely value-based care?

And as you were speaking, I realized no one’s going to switch from being fee-for-service to value-based care. It’s really going to be the new players like Iora that reinvent the system. And so that’s my way of being able to see this acquisition in a positive light is that this is a new player that Amazon could lower costs. They’re not going to be doing business as usual the way the healthcare system operates now. You mentioned we spend 20% of GDP on healthcare and we’re not seeing results and good value and good outcomes. So I think that is something that a company like Amazon can provide.

I also think, and I’m not necessarily saying this in a positive way, but whether we like it or not, you mentioned “know thy patient.” They know us. They have all our data.

Peter Hagan: That’s right.

Teresa Chahine: Different populations are variable, and it’s very localized. And guess what? They have all that information, and if they don’t, they can model it. So I think that’s another thing that they can bring. I know you’re surprised because I spent all of class ranting and saying how worried I was about this, but just based on what you’re saying about what it would take to scale, they have what it takes. You mentioned the convenience factor. I think they can reduce the cost. I think they probably can improve outcomes.

My main concern is that Iora is a values-driven organization, thinking about empathy, why they’re doing this. And I don’t think Amazon is, and as you said in class, culture beats strategy any day, so I worry about that, the culture and the values part. But that’s honestly where it goes back to the government. The government is accountable for health because health is a human right. That’s at least how I think about it. I know many people don’t, but I think that as the sector evolves and shifts over time and new players like this come in, there is a role for community-based organizations and government actors and others to really be at the helm of this, I would hope, and to partner where players like Amazon are working for them, not the other way around. Right?

Peter Hagan: Right.

Teresa Chahine: They’re providing a service, but then I hope they don’t get to make the decisions. I hope that other actors like the government continue to. So we’ll see how this goes down. I don’t feel great about it. I know it has the potential. I will say, at least let them disrupt. Let them prove that you can do it at a lower cost and you can get better value and outcomes because that’s their business is like that aspect. But then don’t let them take over. I don’t know. What do you think about my thoughts?

Peter Hagan: No, I think that’s right. I think a lot of this represents a symbolic shift more than anything else. At the end of the day, I do believe that consumers will vote with their feet too. If they can find a superior primary care model that has certain elements, like they’re getting a health coach in addition to their provider who is able to deliver that higher service bar for what they’re looking for or they’re finding that care is more convenient in some way or they’ve formed a more lasting relationship with provider X over here. I do think that all of those aspects can be incorporated into a future U.S. healthcare model. Right now, not as much as I’d like to see. There’s not as many providers employing those tactics, like having a truly team-based approach with other people other than the doctor/provider looking after smaller panels of patients, taking care of needs that doctors just don’t have time for otherwise.

But I would say that Amazon, they may very well change the game as far as being a disruptor, and I do think the convenience factor that they afford is one aspect of what could carry U.S. healthcare forward. But there’s many different aspects that I think could just be, we have more “copycats.” We loved copycats at Iora, just having people who would adopt some of these same principles and allow them to catch fire. And so I do think that’s a hope that I would have for Amazon and many, many other digital health players that have come onto the scene and hope that things can be designed in a way that makes them interoperable and every source of patient data can start to be seamlessly woven together to get that complete picture and break down some of those silos that exist today where someone might have a redundant medical cost and get the same test done at the same time, three different places just because their records weren’t carried over.

So I do think that’s another strength of Amazon’s, that they may be able to bring that technical capital to help weave much of this together and create a more seamless experience.

Teresa Chahine: I have a student who dreams of creating a digital health wallet where each person has their own health data so that you don’t have that information asymmetry where someone else is using your data and profiting from it, but you own your data.

Peter Hagan: That’s right.

Teresa Chahine: So I don’t know if this is a step in that direction or not, but this is a player that might potentially be able to create that kind of wallet for people. So I don’t know, TBD, but one thing that you said really resonated with me, which is the game needs to be changed.

Peter Hagan: Right.

Teresa Chahine: That is something we know for sure. So for now, it’s just a moment of like, all right, let it be disrupted and let’s see where all this lands.

Peter Hagan: Agreed.

Teresa Chahine: What are your closing thoughts and just words of wisdom for the students after we taught this case twice today, and you got to chat with so many students after class in terms of your hopes for the future and just general trends in terms of value-based care and digital health equity?

Peter Hagan: Yeah, absolutely. So a lot of great questions from your students. I thought they were raising all the right points and going down all the right roads when it comes to how to fix U.S. healthcare. And I think Iora’s model was very radical and revolutionary, and I think the idea was, let’s start from scratch with everything, technology, people, processes. So I think in that sense, it really helped to show what could be done from an aspirational point of view with U.S. healthcare. And I would say to aspiring young healthcare disruptors, I think I was always very much convinced that Iora truly was in this game for the right reasons. And that mission-driven aspect of their role in the marketplace was pretty clear to me.

So I would say for young healthcare disruptors, being in the industry for the right reasons is important, whether you’re looking at a new digital health startup. Unfortunately, there’s so many of them on the scene now that I don’t believe that all of them are truly motivated to make a dent in these endemic problems within U.S. healthcare. And I would say just keep a discerning eye out for teasing out, is this a place that really practices what it preaches with regard to culture and values at the end of the day? Are they truly in this to disrupt healthcare in a positive way that’s going to lead to more value-based healthcare and outcomes that ultimately result in lower cost and better health for people across the country?

Teresa Chahine: And we focused a lot about your history with Iora today. Where can people learn more about what you’re doing right now with Commonwealth Care Alliance?

Peter Hagan: Absolutely. Yeah. So Commonwealth Care Alliance is a nonprofit based in Massachusetts with health plans and a presence in Rhode Island, Michigan, and California. So our focus now is on those with some of the most significant health challenges. Most of our members are dual-eligible Medicare/Medicaid members, and so lower-income with high health and complexity. And I would say the way to learn more about our mission is go on to the Commonwealth Care Alliance website and you can share my contact information as well as part of this podcast. But I work in the digital health sector and IT division of Commonwealth Care Alliance, and our focus is on trying to identify new tools to enhance the member experience, which currently is very hands-on, high-touch, much like the Iora model, but challenging the notion that members need in-person, high-touch experience versus being able to self-serve for some of their needs. And I think members are asking for that, and they want more self-service options.

And digital health affords lots of unique opportunities with that population as far as remote patient monitoring and tracking activities and the health and wellness of our members outside of those rare medical visits that happen because all of the care that happens in between visits and the health that happens in between those visits is really what the healthcare system on the whole needs to tap into more in order to help drive outcomes with regard to chronic disease management in the U.S.

Teresa Chahine: There’s so many different angles that you can chop at these challenges from. It’s really a life’s work.

Peter Hagan: It is, for sure.

Teresa Chahine: Thank you so much for taking the time to share your work with us today.

Peter Hagan: Thank you very much for having me. Appreciate it.

Teresa Chahine: Thanks, Pete.