Start-ups bringing disruptive innovation to primary care

While the term "disruptive innovation" has become synonymous with change that shakes up an industry, it actually has a very specific definition.

Harvard Business School Professor Clayton Christensen coined the phrase almost two decades ago to describe services or products that supplant incumbents because they are more convenient, more affordable and more accessible. The process usually begins with a new player, targeting an overlooked portion of the market, and ends by redefining the entire industry.

Christensen identified retail clinics as a potentially disruptive innovation in healthcare. These clinics, staffed by nurses or physician assistants, would follow standardized protocols to diagnose and treat a small number of routine maladies while letting physicians diagnose and treat more significant problems.

The hope was that retail clinics could provide a cheaper model of healthcare to more people, especially lower income patients who often forgo preventive care and rely on emergency rooms.

Yet that isn't how it turned out. The potential of retail clinics hasn't been fully realized. They are usually located in more affluent areas and their growth has plateaued.

Modern Healthcare spoke to a half dozen prominent healthcare thinkers, asking them to identify the next disruptive innovation in healthcare. They again highlighted primary care.

But this time, they pointed to a raft of new entrants like CareMore HealthPlan, Oak Street Health, IoraHealth and Aledade Inc., which, while using some of the same process-based methods championed by retail clinics, are partnering or employing primary care practitioners in a city or region. These firms are focused on coupling primary care with intensive preventive care to halt or reverse the development of chronic diseases like diabetes, heart disease and chronic obstructive pulmonary disease.

In a world moving to value-based reimbursement, the strategy makes a lot of sense, especially because this new primary care model tends to use capitated payments, rather than traditional fee for service. They take responsibility for the financial cost of patients' primary, specialty, acute, and post-acute care and the overall quality of clinical care with the understanding that they will be rewarded for providing better outcome at a lower cost.

Not surprisingly, large healthcare organizations, which are increasingly using capitated or bundled payment, are starting to pay close attention to the model.

“The tone of the discussion has changed over the past five years,” said Dr. Thomas Lee, Chief Medical Office at Press Ganey Associates Inc. Hospitals were initially skeptical of reducing admission, but are now increasingly keen on learning from these organizations, he added. “The conversation is no longer about if we should do this, but how.”

The new primary care business model generally works like this: the groups actively manage the sickest patients, often offering new services that had not traditionally been part of primary care. To offset the cost, their practices are reorganized around patients requiring similar types of care. They are also making better use technology and data analytics. The goal is to reduce emergency department visits and unplanned hospitalizations while improving overall quality.

Oak Street Health used the model to reduce hospitalizations by about 40%, said Meredith Alger, a researcher at Harvard Business School's Institute for Strategy and Competitiveness. It also received high marks for patient satisfaction and five stars for clinical quality based on the Healthcare Effectiveness Data and Information Set (HEDIS), which is used by 90% of health plans to measure clinical performance.

The primary care model addresses two of the bigger problems in healthcare today: waste and the shortage of primary care physicians. Hospitalizations and emergency room visits are costly and often unnecessary. One study published in the Journal of the American Medical Association found that almost 40% of emergency department visits and roughly 10% to 17% of inpatient hospitalization costs could be prevented.

Meanwhile, U.S. primary care practitioners are seeing more patients with more chronic conditions with less time available for each patient. They are also compensated far less than subspecialists.

These new firms have organized their practices to provide regular check-ups, especially for patients with chronic conditions. Many have same day appointments and offer services 24 hours a day, seven days a week. Some even provide transportation.

In some cases physicians care for fewer overall patients, so they can meet with patients more often and for longer periods of time. A physician at Oak Street, for example, oversees about 450 patients compared with the industry average of 2200 patients, said Alger, adding Oak Street's average appointment takes 30 minutes whereas the national average is about 17 minutes.

Between visits, these companies use phone calls, remote monitoring devices or home visits to monitor patients for psychological changes that could be early warning signs.

Several also offer additional services that encourage their patients to maintain a healthy lifestyle – nutritionists, yoga classes, behavioral health screenings – and they coordinate access to community organizations that can offer housing or employment services.

“It's very individualized caring for patients with chronic diseases,” said Dr. Arnold Milstein, who directs Stanford's Clinical Excellence Research Center.

Dr. Milstein and Dr. Lee recently published separate papers outlining how primary care practices can provide such a comprehensive list of services. A key component, both scholars agree, is standardization. The practice should either focus on a subset of patients, like chronic care for older patients, or divide its patients into groups whose members share the same requirements for screening, preventive care services and evaluations.

For example, Oak Street Health in Chicago stratifies patients into groups with different levels of risk, such as: healthy; healthy with complex acute illness; at risk; chronically ill; and critical. The sickest 5% are seen at least once every three weeks.

CareMore, whose practice focuses on seniors, has teams broken out by specific need: wound healing, risk failing, behavioral disorders, destructive home environments, anticoagulation, elevated blood sugar, elevated blood pressure, and pre-surgical stabilization.

“It helps practices anticipate patient needs,” said Dr. Lee. It also helps physicians to redistribute the workflow so that nurses and non-medical can be in charge of a lot of the follow-up required for preventive care.

For example, front office staff can make eye appointment for diabetics. Medical assistants can track common chronic conditions, like hypertension or lipid abnormalities. The model also allows practices to schedule educational group meetings led by specialists or social workers.

These companies use very narrow networks where a few high-quality, low-cost specialists are used exclusively. A big problem is that primary care providers don't always know what happens after the patient leaves the office.

To solve this issue, some of these companies are also taking advantage of new technology, especially data analytics, that have not been part of traditional care, said Dr. Mark B. McClellan, director of the Robert J. Margolis Center and professor at Duke University.

The former head of the Centers for Medicare and Medicaid Services highlighted Aledade, a practice that identifies the sickest patients most likely to be readmitted to the hospital. It then provides more preventive care to that subset of patients.

It also created a technology system that acts as an information aggregator, combining a practice's schedules, electronic health records and claims data with patient data from hospitals and urgent care centers. It then presents it a way that is actionable, said Aledade co-founder and CEO Farzad Mostashari, who previously served as head of CMS' Office of the National Coordinator for Health Information Technology.

For example, in the morning a doctor can see who is coming in that day along with key insights such as whether a patient failed to pick up a prescribed medication. The doctor can also see which patients just left the emergency room or hospital and need follow up.

“Making information really meaningful for physicians is something we haven't seen really happen yet,” said Dr. Thomas Feeley, head of Institute for Cancer Care Innovation at MD Anderson Cancer Center in Houston.

Lisa Ward is a freelance writer based in Mendham, N.J.