Is a Health Coach Better Than an Overworked Doctor?

Suzanne Koven was walking in the rain when she slipped, fell and fractured her right shoulder. It took surgery and months of physical therapy to heal.

“The recovery was miserable,” she said. But it came with a silver lining.

Koven is a primary care doctor at Massachusetts General Hospital, and the hospital insisted that for her first three weeks back she had to take twice as long to do her job. Suddenly, she had the luxury to actually spend time with her patients, to talk with them about what was wrong and how she could help.

“It was the happiest time in my career,” she said. “It completely transformed the nature of the interaction [with patients]."

That wouldn’t last. When her three weeks were up, Koven had to rejoin a system that rewards quantity over quality. She was back to seeing 20 patients a day.

But just a mile away from her office, at Iora Health's main offices in Cambridge, Rushika Fernandopulle was busy brewing just the kind of medicine that inspired Koven to go into primary care more than 20 years earlier -- a practice that, at its core, is about building relationships. At Iora Health's clinics, teams of doctors, nurses and health coaches work together to take care of patients holistically, bundling together mental health services, peer support groups and nutrition counseling with more traditional primary care services like physical exams.

This model builds on a team-based approach to medicine known as patient-centered care, itself part of a larger movement to cut costs and improve health by upping the quality of primary care. The idea behind it is if people's baseline health is better, the system will have to spend less money paying for expensive emergency procedures later.

Large healthcare outfits, university systems and Silicon Valley upstarts have tried this approach with varying results before. But Iora wants to take this concept a step further by actively going after the most expensive, high-risk patients, spending more time and resources on each one, and investing in building in-house data analytics and IT tools. Along the way, the company is killing the standard model, in which doctors are paid for each service they provide, and redefining what a health provider is.

"What's key to our model is to build a team around the patient" in a data-centric way, said Fernandopulle at the WIRED Data|Life conference in New York City yesterday. They take data from hospitals, pharmacy benefits companies and patients to monitor how patients are doing and to identify what patients to treat in the first place.

So far, he says, this approach has met impressive results. The company has been able to reduce emergency room visits by 48 percent and hospitalizations by 41 percent, resulting in an overall 15 percent reduction in healthcare costs in pilot studies at its four practices in New Hampshire, Nevada, New York and Massachusetts. Plus, the physicians in his clinics tend to be happier.

It's the type of effect that Koven noticed during her three-week stint working at half her normal pace. She doesn't have hard data to back this up, but she noticed that it took her patients roughly 15 minutes to start confiding in her. During a normal 15 minute visit, the patient would never get to that point. More open communication, she says, also made her less likely to order unnecessary expensive tests and medications.

At Iora, that's standard partly because of the way the payment system works.

A provider pays a lump sum of money, usually between $150 and $200 a month, for each patient instead of forking over money per service. Then it's up to the team to decide how to best treat the communities they serve. The system only works if the clinic keeps patients healthy. It behooves Iora to figure out exactly what's wrong and tailor treatment to its patient population.

Sometimes that means cutting back on medications or the number of specialists patients see. It can also involve phone calls, text messages, video conferencing through Skype, or group sessions like Diabetes Clubs during which patients socialize and teach themselves how to best manage their disease.

To do this in a data-driven way, the team surveys patients for feedback and uses that information to tweak how care is delivered. It actively collects blood pressure, blood sugar and prescription refilling data to make sure patients are sticking to their health plan. If they don't refill a prescription, for example, the system creates a task for a health coach to follow up with the patient.

Fernandopulle recounted the story of "Mr. Edwin," a patient with end-stage renal disease and anxiety. His panic attacks sometimes prevented him from getting the dialysis that was keeping him alive, which resulted in 17 emergency room visits and $280,000 in healthcare costs.

His health coach asked him what calmed him down and he said listening to music. She used Iora's discretionary budget to buy him a $45 iPod onto which the health coach loaded merengue music, Mr. Edwin's favorite. Mr. Edwin took his merengue music with him to dialysis, and, Fernandopulle says, that quelled his anxiety and prevented expensive ER visits. This would have never happened in a traditional healthcare setting, he said.

Because that hinges on having a good rapport with patients, the company puts a premium on social skills. A background in health isn't even necessary to get hired as a health coach. For example, before joining the company, some of Iora's best health coaches worked as cashiers at Target and Dunkin' Donuts, possibly the last place a traditional healthcare system would look for talent.

"It's one of the most innovative models out there. What they're doing is trying to start to think outside the traditional confines of who can provide care," said Ashish Jha, a professor of health policy at the Harvard School of Public Health. "You don't need to go to medical school to be a great health coach, to connect with people and motivate them. Those skills exist much more broadly."

But, he says, that's not an approach the healthcare establishment is necessarily ready to adopt in its entirety. The concept of building practices around team-oriented care might be scalable, but a strong leader is critical to make this model successful. "It would take a very special, very large healthcare provider to tolerate this approach. The idea that you're going to get a health coach from Dunkin' Donuts just seems hard to tolerate."

Then, there's the question of whether small companies like Iora can really make a dent in the country's $2.7 trillion healthcare bill. There are hundreds of experiments and pilots around the country trying to redefine primary care, and it's still unclear what will work, says Kevin Tabb, the CEO of Beth Israel Deaconess Medical Center in Boston. "It's not clear that a small company has the resources to really develop sophisticated systems on their own. Google couldn't pull it off."

Still, Tabb says, if one or several of these works out, it could still have a big impact.

And it wouldn't have to be as scalable as you might think. "Five percent of the sickest patients are responsible for more than 50 percent of the healthcare spend," Tabb said. "It may be that we only need to provide intensive care to a small percentage of the population." What Tabb means by "intensive care" is not the intensive care unit of a hospital, but the type of personalized, regular care experimental primary care practices like Iora provide.

What all this says to Koven is that healthcare is very much a service industry. And what sets a good service apart is the ability to listen to customers well and to make them feel like what they say matters. That builds trust.

"Primary care -- or my idealized version of primary care -- actually allows for much more of that storytelling,” Koven said. “I don’t think of talking with patients and getting to know more about them as some warm and fluffy add-on. To me, it’s what medicine is.”

And that's the type of medicine Iora Health is trying to kickstart.