What changes when the practice is paid to keep people well?

In a conventional primary care practice, a longer conversation can be clinically valuable and financially awkward. Rushika Fernandopulle approached that tension as a physician. Iora, founded in 2010, sought to rebuild the practice around a different combination of people, information, and payment. Its distinguishing proposition was not simply that clinicians should care more. It was that a business designed around reimbursable encounters could leave essential work without a reliable way to pay for it.

In a 2015 Commonwealth Fund interview, Fernandopulle described health coaches as central members of the care team. They helped patients navigate practical obstacles and sustain changes between visits. He argued that their value came from relationships and capabilities, rather than being cheaper substitutes for nurses or physicians. That is an attributed account of the model, not independent proof that every coach or practice produced better outcomes. It nevertheless identifies the operating choice clearly: expand the team around the work patients actually need.

The payment question followed immediately. A coach's conversation about food, transport, or a confusing treatment plan does not necessarily resemble a billable medical procedure. Iora negotiated arrangements that could support broader services. The Commonwealth Fund's 2016 review described risk-adjusted monthly payments, sometimes combined with quality, experience, or utilization incentives. The relevant encounter was with the purchasing system itself. A different care experience required a buyer willing to fund a different unit of work.

This joined interests that were related but not identical. Patients needed access and a team they trusted. Clinicians needed time and workable responsibilities. Payers wanted acceptable quality and spending. Coaches needed training, supervision, and a real place in the organization. The design could benefit several parties, but only if the practice had enough capacity to deliver what its contract assumed. A monthly payment creates flexibility; it does not create clinical judgment or community trust automatically.

By the 2021 One Medical transaction, Iora's financial exposure was substantial. The merger filing reported that more than 95 percent of its 2020 revenue came from arrangements in which it received capitated fees and bore responsibility for substantially all of the covered patients' healthcare costs. The acquisition therefore connected two businesses with different revenue patterns, rather than merely adding more attractive clinics to the same network. The filing is useful evidence of the model and its risks, not a verdict on its superiority.

The teaching interpretation is that payment design changes what an organization can attempt, while moving new risks onto its balance sheet. A team can invest earlier in prevention when it shares in the resulting value. It can also lose money when hospital use, patient complexity, contracting assumptions, or execution differ from expectations. Whether a particular service creates value must still be measured. Better intent cannot substitute for appropriate comparisons, complete cost accounting, or attention to who joins and who remains in the program.

Start with one overlooked patient need, then connect it with an explicit staffing decision and an equally explicit funding mechanism. Who performs the work? What authority do they have? How will the practice know that the patient benefited? Which organization captures the economic result? Those questions are useful before promising to transform primary care at scale. Iora makes the system visible: clinical design and commercial design meet in the same consultation, even when only one of them is apparent to the patient.

For a discussion tailored to your team, explore a workshop with Julien.