Four years ago Medgadget awarded Dr. Zubin Damania the “Best New Medical Weblog” award for his hilarious and educational persona, “ZDoggMD.” We came across his name again at last year’s TEDMED where he gave one of the most memorable talks of the event, during which he announced that he was teaming up with Tony Hsieh of Zappos to lead up Turntable Health, the healthcare arm of Hsieh’s Las Vegas revitalization effort known as the Downtown Project. We recently had the opportunity to speak with him about how his efforts to transform healthcare are going.
Shiv Gaglani, Medgadget: Can you describe what makes Turntable Health “disruptive”?
Dr. Zubin Damania: There are three levels of disruption that we’re aiming for. First, we aim to transform the business model at Turntable. Fee-for-service does not exist here; instead we have chosen a membership model that entails a flat monthly fee for patient care. That’s currently at $80/member/month retail, and the fees can come from individuals, employers, or health plans. For that flat fee we take away all co-pays. Since we’re in Vegas, I like to describe it as an “All You Can Treat” buffet. The US healthcare system typically spends only about 4% of its healthcare dollars on primary care; at Turntable we’ve decided to double down on primary care and devote closer to 8-10% of our dollars there. Through that we can then bend the rest of the cost curve and increase value in general, and we can experiment with different technology and care models since we aren’t limited by fee-for-service.
The second area of disruption involves fixing the care model itself, transitioning into a team-based collaborative care system in which non-clinicians play prominent roles. The basic premise is that we build a team consisting of at least a family physician, nurse, and health coach. Everyone on our team discusses each patient in the morning “huddle”, which allows them to learn from and contribute to each other. We also apply what we call a “Worry Score” to each member, which is a score from 1 (very healthy) to 10 (very sick) that helps us with population health management and prioritization of visit and huddle frequency and resources. Someone with a score of 10 is very likely to be admitted to a hospital, if he or she is not already. Someone with a score of 1 may only need an annual huddle or visit. The score is partially algorithmic, based on claims data, etc, , but it’s also partly driven by clinician intuition. We proactively reach out to members at each of these levels in an effort to keep them healthy and out of trouble.
The third disruptive element is the technology. Our partners, Cambridge, MA startup Iora Health, developed an electronic health record – the Iora Clinical Information System (ICIS) – which is a remarkable piece of software because it doesn’t waste resources trying to bill insurance, but rather focuses entirely on collaborative clinical care. The patient portal integrates directly with the record, so patients themselves will soon be able to not only read, but write in the record directly. On the back-end clinicians are given a population management dashboard so they can identify patients with worsening Worry Scores and others with specific conditions such as diabetes and hypertension that need attention. That’s only going to continue getting better, because ultimately the EHR will interface with mobile health and wearable technology. We’re small and nimble and so can make these innovations happen fairly quickly.
Medgadget: That’s very interesting. The idea of having patients view and write to their EHR directly concerns some clinicians and technology vendors, first due to confidentiality and second due to the reliability of Patient-Generated Health Data. Can you describe how you’ve alleviated some of these concerns?
Damania: We strongly believe that patients should own their data and that there should be transparency and collaboration between our members and clinical staff. Since we aren’t documenting for insurance companies it makes it a little easier to share the data, because much isn’t written in jargon. In every clinical room there is complete transparency since there is a large monitor that displays the health record so that patients can see what’s being documented. When there is sensitive information, such as mental health or family issues, we also have a voice-recording system that clinicians can use to privately communicate their thoughts and findings to other people on the team. In terms of Patient-Generated Health Data, we will clearly demarcate which data fields have been entered by patients so that there is no ambiguity.
Medgadget: What have been some of the highlights at Turntable since your TEDMED talk?
Damania: We officially opened in December and have rapidly gained more than 400 members without a major employer sponsor coming online yet. This is pretty remarkable given that Downtown Las Vegas is a difficult location from an economic perspective. We have also partnered with the Nevada Health CO-OP, which offers four different insurance products that include unlimited access to Turntable. This certainly helps those who could not afford the $80/month membership fee since the CO-OP offers these products on the state health exchange, and they are eligible for federal subsidies.
As I alluded to before, we’ve partnered with Iora Health because they offer by far the most advantaged technology that we’ve seen to support a holistic care model in outpatient medicine, and their health coach-centered care model is unrivaled. The health coaches do a lot of the heavy lifting for chronic disease management, and they are specialists in “softer” skills, such as empathy and motivational interviewing. The best way to think about the Iora-Turntable partnership is as follows: If Iora Health were the operating system, Turntable would be the smartphone that runs it. We are like the hardware in that we build facilities and develop contracts with individuals, employers, and payers. And we also create the attached network as we will ultimately contract specialists and hospitalists to better leverage our model across the system.
Medgadget: With the proliferation of healthcare startups we’ve heard of some pretty unusual names. How did Turntable get its name?
Damania: We went back-and-forth on the name quite a few times. The reason we chose Turntable is that it alludes to the beautiful relationship that humans had with music back when it was stored in analog on vinyl. You held it in your hand, with beautiful album art, and you placed it on the turntable as part of a ritual that often involved friends. Warm, analog sound, with 10 tracks that told a story cohesively. Over time music has shifted from analog to digital – 1s and 0s – with individual tracks, MP3s, crappy earbuds, and something was lost, something uniquely human in the music. Doesn’t that feel like healthcare? Turntable wants to restore the personal connection and humanity in healthcare. It may interface with the digital world, but it’s a uniquely analog thing at it’s heart, a human relationship.
Medgadget: Speaking of personal connections, are clinicians and health coaches at Turntable held to a particular standard when it comes to their own health?
Damania: That’s an excellent question. Some of our health coaches and clinicians struggle with the same issues that our members do. We believe this is really powerful since our folks can actually relate better to the patients and work on these issues together. Many are quite transparent in sharing these issues.
The key standard to which we hold our clinicians and coaches is that they need to be there for the patient. If you start becoming judgmental and dogmatic, it can become pretty exclusionary and not lead to the behavior change and clinician-patient relationship that we strive for.
Medgadget: Do you have any advice for current medical students who are entering a tumultuous healthcare system where burnout is playing an increasingly prominent role?
Damania: I often travel around the country speaking and “performing”, and one of my main focuses is on burnout, similar to my TEDMED talk. My take on the current situation is pretty clear. If healthcare continues on the path it has been on, I would advise medical students to just stop. You’re destined to be a cog in a broken machine.
However, I think the future is much brighter than this. There’s so much innovation on the horizon, not just in terms of technology but also in terms of the business and care models. The way the winds are blowing, I can’t think of a more interesting time to go into healthcare. You’ll get to be the human piece of an increasingly technological puzzle, and one of the most valuable people who exists in the digital economy. Go through your training and learn the rules so you can break them later. There will be something for you, even if you have to build it yourself. It’s already starting as evidenced by the number of medical students and recent graduates who are starting companies to fix healthcare.
Medgadget: Given your persona as ZDoggMD, I’m interested in how you used to study when you were in medical school. Any thoughts there?
Damania: One of the highlights was when my friends and I were studying for Step 2. Later on I actually went on to edit one of the Step 2 books because I was friends with Vikas Bhushan (the founder of First Aid). Keep in mind that this was the 1990s, so my friends and I were obsessed with the N64. We used to play four-player multiplayer Goldeneye and MarioKart, and one of us always had a step one prep book open. That person’s job would be to quiz the rest of us by shouting out questions about random topics, such as sphingolipidoses. We made learning fun, and often drew associations through games and music, something familiar to anyone who has watched any of our videos. Every single one of us in that group scored 99% on the boards and we probably had much more fun than many of our classmates!