EP460: Rushika Fernandopulle, MD’s Theory of Change Starts With Status Quo Healthcare

Relentless Health Value™

This is one of those episodes where we consider top-line strategic imperatives and key drivers. I thought there was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Medical and then to Amazon. Listen to the show with Brian Klepper, PhD (EP335) entitled, “Why Is Private Equity Willing to Pay $55,000 per Patient?” for more on that dynamic. It is not what we talk about in this episode. In fact, we talk about almost the opposite of this $55,000 per patient today.

For a full transcript of this episode, click here.

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This is a conversation about actually getting patients great care, great health, great experiences at an affordable price. We talk about how to actually get Americans care that keeps them healthy.

And the reason I set my sights on getting Dr. Fernandopulle on the pod to talk about this is something I heard Kenny Cole, MD—who I interviewed in episode 431—but something that Dr. Kenny Cole told me that Dr. Fernandopulle said during a conversation that the two of them had. The gist of it is this: There’s a lot of innovative stuff that’s going on at this point, kind of around the edges. But if we want to impact the care of 99% of Americans, we have to impact those in the mix who are caring or paying for the care that 99% of Americans are currently getting. And that is the status quo cohort of hospitals and carriers.

Does transforming healthcare or getting patients healthy cause a problem for current tech stacks and contracts peppered with so much conflict of interest it makes your brain hurt? Oh yes, nobody is a spring chicken around here. That’s what pretty much every Relentless Health Value show is on or about at some level.

And this is exactly also why I am a huge cheerleader of anybody who works at a big jumbo anybody who chooses to recognize the downstream impact of their company and of their own work and tries to tweak said impact. Because as I said in that personal charter show at the end of 2024 (INBW41), when there’s millions and millions and millions of patients or members on the spreadsheet, switching up any given vector, what, 0.05% will have a macro impact. Dr. Rushika Fernandopulle says, if you’re going to change anything, you’ve got to have a theory of change.

He has a four-prong theory that I’m going to run through right now. And because I can’t leave well enough alone, I plucked one more prong from our conversation and stuck it on the end. So, this show covers a five-prong theory of change. Here’s the sum-up of these five prongs.

Prong 1: New payment models. We have to have payment redesign if we want actual, real change to happen, such as getting advanced primary care for all Americans. Small detail of note: To actually get real payment design, my eyebrows went up when I heard Dr. Fernandopulle say the same thing I had just heard Lisa Wetherbee from Trinsic say at a recent thINc conference. And it’s also the same thing that Cora Opsahl (EP452) and Claire Brockbank (EP453) from 32BJ said.

And when I say they all said this, I mean, they all said this in a formidable way. They said, you walk into the door of the carrier, whether you’re a plan sponsor or you are a clinical organization, you walk into the door of the carrier with your own paper. You bring your own contract, and you start from your own contract. Do not take theirs and try to hack away at it. This will not result in changing the payment model. And unless the payment model is changed, it’s really hard, it makes it much more difficult to do the rest.

Prong 2: Change the process and innovate a new clinical model. It’s all about teams, real teams, navigators, behavioral health, social work on that team, physical therapists, nutrition, population health, inside of the practice and all that data. It definitely takes a village. Care has to be proactive, not reactive. Can’t wait for somebody to show up when they are already in an acute situation because then we cannot prevent the acute situation.

Of course, all of this is easier said than done, but thinking hard about all of this is the second prong in Dr. Fernandopulle’s theory of change.

Prong 3: A different set of technology tools that are relational, not transactional. Scott Conard, MD, is going to talk about this also in an upcoming show, the whole imperative to be relational and aligning infrastructure and tech and how data is used around that relationship.

Tom Lee, MD, talked about that also in a recent show (EP445).

Prong 4: Change the culture. Doctors have to be on board and want to work on a team. And then that team has to be competent and take ownership and accountability.

There’s so much cynicism (and rightfully so) where doctors have been told, you know, go ahead and leave your shift. There’s a team that’s gonna help out and keep patients in good shape. And so often that has turned out to be a false promise. And so, team-based care and working at the top of your license basically became synonyms for cutting costs to maximize profits.

So, yeah … we have to reset on that in such a way that doctors really want to be part of the change.

Prong 5: (Again, I’m adding this one to the end. This prong gets discussed, but it kind of came out organically. It wasn’t part of Rushika’s original list.) Make collective action, collaboration, happen. That’s prong five. Think about creating long-term partnerships. If there’s a giant beast of a market power in any given market, ganging up together is a strategy with a lot of historical success to combat that giant beast of a market power.

To this end—and I’ve said this several times in several recent podcasts, including the Thanksgiving show—but in that Trilliant report and also in a recent Advisory Board podcast, as well as a bunch of other articles I’ve read, I keep hearing over and over and over again that organizations who are good at forming payer/provider partnerships and/or plan sponsor/provider partnerships and/or plan sponsors ganging up together and/or other types of partnerships have a very big competitive advantage over those who are fighting tooth and nail with each other or trying to do stuff all by their lonesome. So that’s prong five.

Also mentioned in this episode are Brian Klepper, PhD; Kenny Cole, MD; Lisa Wetherbee; Cora Opsahl; Claire Brockbank; Scott Conard, MD; Tom X. Lee, MD; Beau Raymond, MD; David Muhlestein, PhD, JD; Zack Cooper, PhD; Suhas Gondi, MD, MBA; and Chris Skisak, PhD.

Additional related episodes: EP414 with Justina Lehman; EP409 with Larry Bauer, MSW, MEd; EP417 with Josh Berlin, JD

You can learn more by following Dr. Fernandopulle on LinkedIn.

Rushika Fernandopulle, MD, is a practicing physician who was the co-founder and CEO of Iora Health, an early innovator in primary care redesign. Iora was acquired by One Medical, and then the combined company was acquired by Amazon. Prior to this, Dr. Fernandopulle was the first executive director of the Harvard Interfaculty Program for Health Systems Improvement and managing director of the Clinical Initiatives Center at the Advisory Board Company. He is a member of the Schweitzer, Ashoka, Aspen, and Salzburg Global Fellowships and is co-author or editor of several publications, including Health Care Policy and Uninsured in America: Life and Death in the Land of Opportunity. He serves on the boards of the Asian American Foundation, Families USA, and Premera Blue Cross. He earned his AB, MD, and MPP from Harvard University and completed his clinical training at the University of Pennsylvania and the Massachusetts General Hospital.

06:39 How Dr. Rushika Fernandopulle found himself where he is now.

08:06 Dr. Fernandopulle’s conversation with Kenny Cole, MD.

10:33 Why is it important to have new payment models?

12:21 EP453 with Claire Brockbank.

14:50 EP455 with Beau Raymond, MD.

16:19 Why it makes sense to change as quickly as possible.

19:55 How to be proactive and not be reactive and achieve value-based reimbursement for good care.

21:41 Why team-based care is so important for change.

23:37 Why is it important to have a different set of technology tools?

24:38 EP391 with Scott Conard, MD.

25:24 Why changing the culture is important.

27:01 “Getting doctors to do things they don’t like is a waste of time.”

33:22 “Healthcare is local.”

35:31 EP364 with David Muhlestein, PhD, JD.

35:43 Study by Zack Cooper, PhD.

36:53 EP404 with Suhas Gondi, MD, MBA.

39:04 Why long-term partnerships are the only way to make things better.

You can learn more by following Dr. Fernandopulle on LinkedIn.

@rushika1 discusses #statusquohealthcare on our #healthcarepodcast. #healthcare #podcast #changemanagement #healthcareleadership #healthcaretransformation #healthcareinnovation

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