We need to limit the influence of corporate lobbyists in the industry. The interests they represent are all about big health systems and large national payers, because that’s where the money is. Those deep pockets are the ones setting the context and pushing policy makers to make decisions that don’t always consider an actual patient’s or community’s best interests. Rarely represented are the independent healthcare providers who are so often the bedrock of healthcare for the average American — they know what their communities need. We need to give them a political voice.
As a part of our interview series called “5 Things We Must Do To Improve the US Healthcare System”, I had the pleasure to interview Kyna Fong.
Kyna Fong is CEO and Co-founder of the independent primary care platform, Elation Health. She was a Robert Wood Johnson Fellow in Health Policy Research and Ph.D. health economist on the faculty at Stanford University before starting the company in 2010.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
When I was a teenager, I helped my father run his small primary care practice in Walnut Creek, California. Our family had moved from Canada to the US so that he could pursue the freedom of independent practice and the delivery of high-quality personalized care. At the office I’d work the front desk, greet and room patients, and spend an inordinate amount of time on the phone with insurance companies making sure we got paid for our work.
What struck me deeply from my experience there was how trusted my father was by his patients and how much that patient-physician relationship mattered to their care. I could also see how integral primary care was to healthcare. Primary care is the front line, where the patient journey begins and often ends. Primary care goes beyond the physician’s ability to treat whatever medical issues crop up in a patient’s life — it supports consistent, first-contact, longitudinal care.
I eventually left for college to study computer science and later earn a PhD in health economics, but what I learned at my father’s practice stuck with me. I knew there must be a better way to support independent primary care practices and that’s the platform we’ve built at Elation.
Can you share the most interesting story that happened to you since you began leading your company?
Over the last decade, there’s been a consistent thread in media headlines about independent primary care practices “going extinct” or not being able to adapt to the modern demands of healthcare. We’ve always known it wasn’t true. When COVID-19 hit, it was pretty amazing to see that belief in action. Everything changed for these doctors in a matter of days. They suddenly had way more demand from their worried patients but couldn’t safely see them in the clinic — yet, those in-office visits were really the only way these practices could pay their bills. Even big hospitals with million and billion dollar endowments were out there talking about lay-offs and closures.
The industry responded fairly quickly with expanded coverage and infrastructure to support telemedicine, and these independent primary care practices — they just kept going. It was inspiring. In a matter of weeks, so many of our clinics switched to telemedicine. They were communicating with patients, opening up curbside visits, and keeping their businesses running. After the first few months, it was clear that our community practices wouldn’t be laying off staff or closing any time soon. We even heard from a couple doctors that last year was a really successful year for their offices. All this to say, I don’t think we give enough credit at all to independent primary care practices for their adaptability and resilience. They’re able to thrive in very challenging situations, always with the focus on what’s best for their patients. I think it bodes very well for the continued success of this segment in healthcare.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
The second doctor after our dad whom we convinced to use our system was a family friend. What we didn’t realize was that he didn’t know how to use a computer — he couldn’t type or use a mouse. It was a pretty big challenge that we didn’t expect to encounter.
The experience was so valuable for us though because it strongly reinforced the importance of user empathy in building great products and how we had to put ourselves in our customers’ shoes and question our assumptions. Not every doctor is computer-savvy or a tech wiz. In fact many doctors are in a similar boat as our family friend. We learned to reexamine our assumptions of how a user on our platform might struggle. That doctor eventually did learn how to navigate a computer and found it very empowering. We were rooting for him all the way.
What do you think makes your company stand out? Can you share a story?
We’re one of few companies in health technology that is truly in the physicians’ corner, which I wish were not true. If you think about electronic health records, most of these systems are designed for administrative and billing compliance, and therefore for administrators. How doctors feel about using the technology, how it impacts their relationship with the patient, how it even drives them to serious burnout — it’s just not part of the EHR business today. At Elation, we’ve always put the clinician first. It’s natural, since we started building the platform for my dad and his practice. And we’ve shown over the years that there’s a lot of lasting value in that focus. Elation is intuitive to use, and we are delighted to be a technology platform that helps doctors enjoy their practice and spend higher quality time with their patients (not just deliver more services).
Primary care is the lifeblood of our healthcare system. Primary care physicians get to know a patient over time, building a sustainable relationship. This helps intercept health problems before they become monumental and creates a partner to help manage bigger problems if they arise. This is where the independent primary care physician thrives, but in our current healthcare system, this relationship is under attack and has been undermined for a long time.
How can physicians establish trust with patients if they can’t spend enough time with them? How can a physician really engage with a patient if there’s a timer running in the background? How do we avoid burnout if the physician has to do 2 hours of documentation for every 1 hour of direct patient care? The thing that makes independent primary care so valuable — the relationship — is also what makes it vulnerable in a pay-for-volume system where primary care is under-resourced. Elation is dedicated to supporting the success of independent primary care, and we’re doing that by building technology that helps these practices evolve to meet the needs of value-based care more efficiently. That way, they can focus on their craft of helping their patients.
What advice would you give to other healthcare leaders to help their team to thrive?
Focus on the fundamental humanity of what healthcare is. There’s a lot of “disruptive” technology aimed at the healthcare industry that fails to consider what it’s like to be a physician or to be a patient. As a result, there’s little movement of the needle on outcomes either. When you’re really listening to the actual people involved in patient care and thinking about their needs, what you build is much more powerful. That’s also a vision teams can get behind, because they know they are empowered to make a real difference in society.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
U.S. healthcare is broken in so many ways, but arguably first and foremost because of our third-party employer-based approach to health insurance. It leads to price inflation. It leads to millions being uninsured and under-insured. And it leads to too much “sick care” instead of “health care”. In 2020, there were 31 million Americans without health insurance, and many more underinsured. This creates a huge barrier to the kind of care that keeps people out of hospitals and emergency rooms. And when they wind up in the ER or hospitalized, often for a catastrophe that could have been prevented “upstream,” the costs are astronomical. Families go into overwhelming debt, healthcare bills go unpaid, and hospitals translate those costs into higher billing rates for “paying customers” — the ones who have insurance.
Another challenge is our political system. There’s solid consensus that some form of universal primary care would significantly benefit the U.S., yet we haven’t been able to get both sides to agree on policy that ensures healthcare, like infrastructure and national defense, is something that should be provided for the public good. The United States is beautifully diverse, which creates a rich and complex culture, and yet when compared to other advanced countries, it has been harder for the U.S. to adopt national policies to achieve that level of safety net with healthcare. People tend to blame the fee-for-service payment system for our problems, but I think that’s a symptom of our failures, not the disease.
To return to the point about preventing health issues upstream, that is the role of effective primary care and the US invests very little in primary care: while the average OECD country spends 14 cents of every healthcare dollar on primary care, the US spends 5 to 7 cents, less than half! The case for controlling costs is clear: for every 1 dollar invested in primary care, at least 13 dollars is saved in downstream costs. We also know that when it comes to patients, more primary care is better — life expectancy, quality of life, health disparities, all of that gets better. No other specialty in medicine can make this claim. It’s clear that the healthcare crisis in the U.S. cannot be solved without a strong foundation in primary care.
Now even if every American had a primary care physician, we still need to give primary care the tools needed to do the job. For example, STAT reported that only about half of U.S. physicians are usually notified when a patient goes to the ER or is admitted to the hospital. That’s a big gap. Yet, 79% to 85% of physicians in the Netherlands and New Zealand reported usually receiving these notifications. Additionally, only half of U.S. doctors reported being able to exchange patient information with physicians outside their practices, yet, 72% to 93% of physicians in the Netherlands, New Zealand, Norway, and Sweden are able to. This kind of information exchange is key to reducing the fragmentation in healthcare that creates so much chaos, and who better to coordinate and integrate it all than the primary care physician, who manages the “whole patient”? The more we share information, the better the healthcare system can work collaboratively to keep patients healthy, well, and out of the hospital.
You are a “healthcare insider.” If you had the power to make a change, can you share three to five changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
There are so many small and large changes that are needed, but here are a few that come to mind.
- Political leaders and legislators at all levels of government who make decisions about healthcare policy need to be more aware of the impact of their decisions on patient care. These policy makers likely wouldn’t make life harder for community-based primary care if they understood what the work of these providers was actually about. It’s about trust, relationships, and ultimately getting patients to adopt healthier behaviors. If the legislators making decisions actually understood how “health” happens and where money and resources are being wasted, they would likely make better policy decisions.
- Secondly, we need to limit the influence of corporate lobbyists in the industry. The interests they represent are all about big health systems and large national payers, because that’s where the money is. Those deep pockets are the ones setting the context and pushing policy makers to make decisions that don’t always consider an actual patient’s or community’s best interests. Rarely represented are the independent healthcare providers who are so often the bedrock of healthcare for the average American — they know what their communities need. We need to give them a political voice.
- We also need more rapid changes to policy that addresses payment innovation and aligns the public and private insurance sectors around value-based reimbursement models. We are seeing CMS play an impactful leadership role in moving payment innovation in the right direction for government programs, but sustained change needs to happen faster. Commercial payers and self-insured employers also need to follow suit in shifting reimbursement models away from fee for service towards models that pay for value, and continue to drive investments in care that improves outcomes and lowers costs.
- Lastly, let’s get our best technology talent working in healthcare and tackling smart solutions to some of our biggest problems. For example, take interoperability and combatting fragmentation of information. Thankfully, we’re seeing progress with health information exchanges in some areas of the country, but it won’t matter until we go the last mile and get that information into the hands of clinicians who are making decisions about real patients. The healthcare industry often tries to solve problems by throwing more people at them. But technology can do a lot of this work for us, reducing costs, eliminating errors, and preserving human attention for activities that require human touch. Let’s drive more creativity and innovation in how we leverage technology in healthcare.
Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
We’re really honored at Elation Health to have a role in the success of independent primary care in the U.S. Today, we are helping over 14,000 clinicians deliver the most cost effective healthcare to over 7 million patients. It’s our mission to not just keep these important medical practices open (often serving the highest risk patients: rural, elderly, indigenous, and people of color) but to help them thrive and be truly rewarded for the incredible value they bring to society.
On your other points, I will focus on how those various parties can help support effective primary care. For individuals, you can start by finding and developing a relationship with an independent primary care doctor for yourself. Simply by making that choice, you’ll be getting much more personalized, effective, and compassionate care. Educate yourself on how to make the healthcare system work for you and your family, and ask questions about the best ways for you to stay healthy and prevent illness. Vote often, and consider healthcare issues when you cast your votes for leaders at all levels.
For corporations, remove all barriers to accessing independent primary care and mental health care as an employee benefit — this is something that delivers massive returns. There’s a reason more and more companies are investing in employer-sponsored primary care platforms for their teams.
For communities, give your local primary care doctors a voice and listen to what they need, both for their clinics and their patients. These doctors know the community best and are out there educating individuals and advocating for key public health issues like vaccinations, clean air, mental health resources — they are everyday heroes.
And, finally, for leaders: please keep independent primary care top of mind in finding new ways to reward their contributions that don’t add massive administrative burden nor make it harder to take good care of patients.
I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
As a starting point, the data suggests significant opportunity to better integrate behavioral health into primary care:
- 80% of people with a behavioral health disorder will visit a primary care provider at least once a year
- 50% of all behavioral health disorders are treated in primary care
- 48% of appointments for all psychotropic agents are with a non-psychiatric primary care provider
- 67% of people with a behavioral health disorder do not get behavioral health treatment
- 30–50% of patient referrals from primary care to an outpatient behavioral health clinic do not make the first appointment
Mental health care needs to be as much on the front lines of healthcare as primary care, but stigma, capacity, and affordability all create obstacles for patients. One way to de-stigmatize it and make it easier for patients to access is to integrate it into the primary care delivery platform and really leverage the trust between a doctor and patient. If a patient has a mental health issue but doesn’t feel comfortable seeking outside help for it, then having a mental health provider integrated into the primary care team can make all the difference.
Primary care is a safe place for patients to go and address health issues before they become catastrophes. This kind of first contact care designed to keep patients well should absolutely include mental health. Some exciting progress is being made — the American Medical Association (AMA) recently launched the Behavioral Health Integration (BHI) Collaborative to widen access to behavioral healthcare by providing support to doctors working to combine mental and physical health services in their practices. Several leading medical associations are joining the AMA in this initiative. This is a great start to more widely integrating mental health into primary care.
Recently COVID-19 has been a powerful motivator for people to overcome obstacles and seek mental health services. Unfortunately, through the pandemic people have been facing physical stress, financial pressure, isolation, not to mention unemployment or working in unsafe conditions in order to keep a roof over their heads. Mental health providers, who were already in short supply, have become a kind of the first responder during this crisis. Demand is higher and access is even harder. Adding to the challenge is coverage — while mental health parity in insurance benefit programs is improving, a lot of mental health providers still don’t take insurance because they don’t want to deal with the overhead of payers. This is a challenge we need to address to expand access to mental and behavioral healthcare.
How would you define an “excellent healthcare provider”?
For me, it starts with earning patients’ trust. That’s the core of the patient-physician relationship. An excellent physician is not only deeply knowledgeable in medicine but also able to guide patients and their families through the hardest, most emotional conversations of their life — end-of-life care, difficult diagnoses and treatments, and so forth.
The way our current healthcare system is set up tends to react with expensive treatments, at times ignoring the patient’s individual journey. In those moments when patients are scared and confused or facing uncertainty, compassion and comfort combined with sound medical expertise can make all the difference. An excellent primary care physician who has built a relationship with their patient over time and gained their trust can alter these experiences for patients and their families in ways they’ll never forget.
Patients want care that is easy to use, available when they need it, from a physician who knows them and will treat them “well”. This is what excellent healthcare looks like.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
Sir William Osler famously said, “It is much better to know what sort of a patient has a disease than what sort of a disease a patient has.” I love this for two reasons. First, it’s a reminder that healthcare is first and foremost human — it’s so much more important for the physician to know the patient than for the physician to be an expert in every detail of medicine. This is that relationship I keep coming back to. Secondly, it’s a reminder that as a health technology company, it’s more important for us to be attuned to our clinical users and their needs than to get caught up in the innovation stream of shiny objects or what the industry zeitgeist says is the priority. That’s why we take our “clinical first” approach to product design and focus on doing all we can to support the people on the front lines who are actually doing the work of caring for patients.
Are you working on any exciting new projects now? How do you think that will help people?
We are focused on adding on technologies and services that will help primary care practices not only survive but really thrive. For example, we are launching robust end-to-end financial products and services to free up our practices to focus on patient care and have confidence they’ll get paid for their work without a bunch of hassle.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
It’s hard to make a list! Over time I’ve found inspiration to be a better leader in many often unexpected places. In terms of regular media, as an entrepreneur I love podcasts like “Masters of Scale” and “How I Built This with Guy Raz” and as a healthcare enthusiast I keep myself up to date with regular industry news sources as well as industry newsletters like HISTalk and Health Tech Nerds. My reading list is usually some combination of child-rearing and business/leadership books.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
For every single person in America to have a primary care doctor they trust!
How can our readers follow you online?
@kynafong on Twitter and LinkedIn
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.