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

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 ✉️ Enjoy this podcast? Subscribe to the free weekly newsletter 🫙 Support the podcast with a small donation to the Tip Jar 🎤 Listen on Apple Podcasts 🎤 Listen on Spotify 📺 Subscribe to our YouTube channel === CONNECT WITH THE RHV TEAM === ✭ LinkedIn ✭ Threads ✭ X ✭ Bluesky 00:00 Introduction 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? 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? 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." 35:43 Study by Zack Cooper, PhD. 39:04 Why long-term partnerships are the only way to make things better.