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Reimagining primary care in an era of chronic diseases

Doctors’ clinics can often be sterile environments where patients occupy the waiting time reading old magazines, spend mere minutes with their physicians and then hurry off to other appointments.

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Doctors’ clinics can often be sterile environments where patients occupy the waiting time reading old magazines, spend mere minutes with their physicians and then hurry off to other appointments.

Not at Iora Health, a clinic with yoga, books and cooking classes, and where patients get as much as 90 minutes of consultation time each visit.

It is one of a small but growing number of clinics around the world that is trying to do primary care differently in an age of chronic diseases — by targeting behaviours.

Iora Health, a primary care group with 34 centres across the United States, and rapidly growing, eschews the traditional clinic set-up and physician-consult-based model, offering patients a homely environment that exudes warmth, security and perhaps even a sense of family.

Beyond the aesthetics, what differentiates Iora Health is its extensive use of health coaches and a team-based model.

Every patient is assigned a health coach, who works with a supervising physician and a behavioural therapist. The health coaches can be former yoga teachers, fitness instructors or even retail assistants — the very first health coach employed was a sales assistant from Home Depot who “loves interacting with people” — and they work with patients on personalised holistic plans, encompassing medical, social and lifestyle needs.

Today’s patients tend to have diseases like diabetes, heart failure and chronic lung disease, explained founder Dr Rushika Fernandopulle, a Harvard-trained physician. So what matters are behaviours that are, in turn, influenced by attitudes and beliefs.

“We recruit for empathy,” Dr Fernandopulle proclaims. “Everything else can be taught.”

Medicines are only one part of the treatment plan. The health coach supports patients in changing their lifestyle and behaviour, through a regular mix of in-person sessions, phone calls and emails.

Every day, the team “huddles”, during which health coaches discuss patients, collectively brainstorm issues and support each other in caring for their patients better.

The Iora Health model costs double that of a conventional primary care practice, Dr Fernandopulle said, but it also keeps patients healthier. Iora Health patients see a 20 per cent or higher reduction in hospitalisations and these savings more than pay for the higher primary care costs.

Across the Atlantic, South Somerset in England has deployed health coaches with similar success, with early results showing a 42 per cent reduction in emergency admissions, a 4 per cent drop in accident and emergency department visits, and a 15 per cent fall in outpatient appointments.

These impressive savings prompt insurers and large employers such as Boeing to sign up.

An insurer or employer would pay Iora Health a fixed sum for each patient for outpatient care that would be higher than the usual charges, but these organisations also expect substantial savings on hospitalisation bills.




In California, Livongo (an abbreviated ‘‘Life on the go’’) is working to revolutionalise diabetes care. Instead of conventional clinic-based models that leave patients to figure things out in their day-to-day activities, Livongo aims to use bite-sized personal and clinical data to drive behavioural change in real time, using smartphone-based support.

“Managing a chronic condition is a time-consuming and costly endeavour,” Livongo says on its website, adding that it “reduces that burden” by adopting the latest technologies and behaviour sciences insights, combined into a mixture of behavioural nudges and human coaching delivered digitally.

According to founder Glenn Tullman, patients want to know just enough to live full lives despite their illnesses. He compares Livongo with modern devices such as smartphones that the average person can use with minimal or no training.

The technology is humming in the background but consumers do not need or want to know how it works, just that it does, and it does within the construct of their lives.

In other words, the technology fits into our lives and makes our lives better in ways we want. After all, patients do not need to know the intricacies of diabetes pathology; they need to know what to eat for lunch or what sort of exercises to do on any given day.

At home, Holmusk, a Singapore-incorporated health data analytics company with operations in Singapore and the US, estimates that only a third of chronic disease management success is decided by medicine.

For the remaining two-thirds, success can be attributed to changes in behaviour. Using insights garnered from patient clinical and lifestyle data, Holmusk is rolling out programmes for mental health and diabetes.

In this era of chronic diseases, we need to change behaviours, not write more prescriptions.

Professor Tai E-Shyong from the National University Hospital has described this as the ‘‘8,759 hours’’ paradox: Patients see their doctors on average four times a year, or an hour annually; the remaining 8,759 hours of the year, they are left to fend for themselves.

What Iora, South Somerset, Livongo, Holmusk and other innovators are challenging us to do is to embrace a versatile, truly patient-centric health system that customises and adapts to what patients want and need to live long, healthy lives.



Dr Jeremy Lim is a partner in Oliver Wyman, the global consultancy and leads its Asian healthcare practice.

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