Episode 460

How Disruptors Can Scale to 99% of Americans: A Theory of Change for Healthcare with Rushika Fernandopulle, MD. EP460

Jan 9, 2025

41:04

Health Equity Public Health Primary Care

Episode Description

How Disruptors Can Scale to 99% of Americans: A Theory of Change for Healthcare

Advanced primary care disruptors — Iora Health, Oak Street, ChenMed, One Medical — proved better outcomes at lower cost are possible. But even combined, they serve a low single-digit percentage of Americans. Dr. Rushika Fernandopulle, founder of Iora Health (sold to One Medical, then Amazon), argues the next challenge is getting the status quo — the hospitals and carriers caring for the other 99% — to adopt what the disruptors proved. In this episode, Stacey Richter speaks with Dr. Rushika Fernandopulle, MD, founder of Iora Health, about his five-prong theory of change for transforming American healthcare at scale — and why it has to run through the existing delivery system to matter.

WHAT YOU'LL LEARN

✅ Why innovating the clinical model without first changing the payment model is a waste of time — and why providers should walk into carrier negotiations with their own contract, not the carrier's

✅ How the 60% threshold works: once 60% of a practice's patients are in value-based payment arrangements, it becomes financially viable to treat everyone that way — and why moving fast to that threshold beats a slow, incremental transition

✅ Why running fee-for-service and value-based care from the same clinical setting is an "unholy mess" — and how to build a separate care model with people who actually want to work that way

✅ How Iora Health reduced hospitalizations by 40% using team-based care — health coaches, integrated behavioral health, social workers, and embedded population health management — and why this model can't coexist with a fee-for-service mindset

✅ Why health systems have two and only two options as Optum and private equity groups move into local markets: get into risk and capture the surplus themselves, or watch someone else do it and inherit a shrinking pie of uninsured patients

✅ Why long-term payer-provider partnerships — not annual re-bidding — are the only mechanism that can sustain this kind of transformation, and what a 10-year Humana contract taught Dr. Fernandopulle about collective action

WHY THIS MATTERS

Disruptors like Iora showed it can be done — great care, great health outcomes, affordable cost. But the math is unforgiving: if you want to impact the care of 99% of Americans, you have to go through the status quo cohort of hospitals and carriers. As Dr. Fernandopulle put it, the current path is unsustainable — close to $5 trillion a year spent with embarrassing outcomes on life expectancy and maternal mortality. The only options are to design the transition well, in a controlled way, or wait for things to collapse.

MENTIONED IN THIS EPISODE

EP453 with Claire Brockbank: Apple Podcasts | Spotify | Other Apps

EP455 with Beau Raymond, MD: Apple Podcasts | Spotify | Other Apps

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP364 with David Muhlestein, PhD, JD: Apple Podcasts | Spotify | Other Apps

EP404 with Suhas Gondi, MD, MBA: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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