How One Medical turned doctors into designers

Repeat Customer podcast, season 2, episode 2

As a patient visiting the doctor, have you ever even considered yourself a customer entitled to a pleasant experience? Well, that's what primary care physician Tom Lee set out to provide when he founded One Medical. But how does one doctor change deeply ingrained inefficiencies in a system as large as the U.S. healthcare system?

Lee describes how he thought like a designer—not a doctor—in his quest to rearchitect the patient experience, while current One Medical CEO Amir Rubin describes the integral role technology plays in their plan. Merchant Medicine CEO Tom Charland demystifies the curious role insurance plays in the medical system. And from the world of health management academia, Kim MacPherson envisions the future of primary care thanks to clinics like One Medical.

Featured in this episode:

  • Dr. Tom Lee, Founder of One Medical and primary care physician
  • Amir Rubin, President and CEO of One Medical
  • Tom Charland, CEO of Merchant Medicine
  • Dr. Navya Mysore, primary care physician
  • Kim MacPherson, Executive Director of Health Management at the UC Berkeley Haas School of Business

Repeat Customer is an original podcast from Zendesk about great customer experience.

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Transcript

[Erika Heald]
So, what was awesome is you walk through the door and for me at least, it felt like my living room because it was full of beautiful mid-century furniture. You know everyone in there was pleasant and happy and there was great music playing.

[Mio Adilman]
Erika Heald is describing the first time she checked out this cool new place in her neighborhood. She uses words like awesome, beautiful, and happy.

[Erika Heald]
It was just such a great atmosphere versus your typical doctor's office.

[Mio Adilman]
Sounds more like a café or spa, not a doctor's office.

[Erika Heald]
Which would have terrible, worn out vinyl chairs and some horrible daytime television playing on a TV. It was just a much more pleasant experience, and my appointment even started on time, which never ever happened at the HMO.

[Mio Adilman]
Right, because this isn't your usual health maintenance organization, this is One Medical. Welcome to Repeat Customer, an original podcast from Zendesk about great customer experiences, how companies create them, and why their superfans love them so much. I'm Mio Adilman and Zendesk is a customer service and engagement platform, and today we're looking at the changing face of primary healthcare through a new type of customer experience for patients at One Medical.

[Amir Rubin]
One Medical is a modernized healthcare experience, designed to serve the needs of consumers. We combine digital health and video visits, and lovely, inviting offices, which are convenient to where you work, shop, live.

[Mio Adilman]
As a patient, have you ever even considered yourself a consumer deserving of a good healthcare experience?

[Intercom]
Dr. Bruce to telephone please, Dr. Bruce—telephone.

[Amir Rubin]
If I could diagnose the existing healthcare system, it's bloating, it's anxiety, it’s depression, it’s constipation, it's broken bones, it's acute but it's also systemic behavioral problems.

[Mio Adilman]
Amir Rubin is the CEO and president of One Medical, and the patient we're treating today is the American healthcare system, specifically primary healthcare, the day-to-day management of your health, usually by a family physician or general practitioner, who handles initial diagnoses and manages chronic conditions. But, the diagnosis for traditional primary healthcare itself doesn't look so good.

[Amir Rubin]
Consumers are frustrated with their experience. It's a maze navigating the healthcare system. How do I get an appointment? How do I get access? Where do I go? Which number do I call? It's, on average, three to four weeks to get an appointment with the primary care physician in the United States, and the cost of care is going up each year. So not only consumers, and employers, and the people who pay for healthcare are frustrated, but if you actually look at the people delivering the care, providers are burning out.

[Mio Adilman]
That's a lot of pain points in a system that's supposed to cure your pains, and many of us, patients and doctors, have just sort of become resigned to this reality. But then there's this guy.

[Tom Lee]
My name's Tom Lee, I'm the founder of One Medical.

[Mio Adilman]
Tom Lee comes from a family full of doctors, based in the Pacific Northwest.

[Tom Lee]
But I was also interested in the arts, and so I was like, "Do I go into medicine, or maybe consider graphic design?" But to me, it was harder to make a living in graphic design, so I ended up going into medicine, a little bit through a plan B option, but it ended up being a great passion of mine.

[Mio Adilman]
It's not a bad plan B option.

[Tom Lee]
Yeah.

[Mio Adilman]
But, what was it specifically about patient care that you really liked?

[Tom Lee]
Well, you know for me, maybe it's just my nature, but I like caring for people in general, and giving people a pretty thoughtful experience.

[Mio Adilman]
I'm guessing most people go into medicine to help others, it's noble and idealistic. You take the hippocratic oath, go forth and heal, which is what Tom did while training at the University of Washington, and during his residency with a specialty in primary care at the Brigham and Women's hospital in Boston. Over time though, something got in the way of that.

[Tom Lee]
It was pretty apparent that no matter what setting I was in, the system of care was this imaginary force that was preventing me from doing what I thought was better for the patient, better for the system, and nobody could explain why it was doing what it was doing. When you're trying to invest in primary care relationships and getting to know people, seeing people in five to fifteen minute bursts on a very sporadic reactive basis seemed antithetical to what longitudinal patient care should be. So there was something imaginary that I wasn't sure about that was creating this force, and I later found out it was really the economics of healthcare.

[Mio Adilman]
I'm not an economist, and definitely not a doctor. So I found a guy to explain the economics of healthcare. His name is Tom Charland, he's the CEO of Merchant Medicine, a company that helps medical organizations become more consumer focused.

[Tom Charland]
Primary care is the magnet for patients to come in when something is wrong, or even just for your annual wellness physical, but the way primary care is paid for is through those office visits, and in most cases primary care is not a profitable specialty. It's considered the generator of downstream revenue to all of the specialists, and in that is a part of this perverse system we have, because primary care doctors don't have time to really sort out what's going on with a patient.

[Mio Adilman]
Under the current system, in order to be profitable primary care has to be high volume, which is why they have so little time for you, and why you often get referred to a specialist, many times unnecessarily, which costs the system even more money. It's also why they'll usually only examine you for one condition or issue at a time.

[Tom Charland]
We create incentives for more and more activity, and so that means a lot of unnecessary care. Every activity has a code, and that code corresponds to what you're going to get paid.

[Mio Adilman]
An insurance code.

[Tom Charland]
Which basically means what was the complexity, how much did you do? For example, if you want a prescription renewal, you would have to call a doctor and say, "My prescription is about to run out." And they'd say, "Okay, you need to come in for an appointment." Just to renew your prescription. The pricing mechanism of insurance really does determine a number of things that would in any other industry just be a no-brainer. You'd provide the service to the customer with a smile on your face.

[Mio Adilman]
So, you get less time with a doctor, and the doctor's really overworked. Like, it's bad for their health overworked. On an average day, how many patients do you think you would see?

[Navya Mysore]
Typically I would say anywhere between 30 to 45 patients.

[Mio Adilman]
I mean, that's a lot of people.

[Navya Mysore]
That's a lot of people. It feels like they’re just a number.

[Mio Adilman]
Dr. Navya Mysore is a primary care physician working in Manhattan. She's talking about life at her last job.

[Navya Mysore]
You're feeling burnt out because of the quantity. You've got paperwork, and you've got labs, and all of which where you're not left feeling satisfied that you were able to deliver the quality of care that you wanted to.

[Mio Adilman]
This sounds just like One Medical founder Tom Lee's experience.

[Tom Lee]
If you're truly an empathetic designer, and you said, "Well jeez, if I've got a person who's newly diagnosed with cancer, or some tremendous illness, what would I design for them?"

[Mio Adilman]
You just referred to yourself as a designer. I don't think I've ever heard a doctor refer to themselves as a designer.

[Tom Lee]
Yeah, you're probably right. I think that crossover is not as common, because they're very different disciplines, but yeah, I viewed myself as somebody who, if you think about going to a restaurant or any other service design experience, there is a design experience that matters.

[Mio Adilman]
Comparing the customer experience of dining at a restaurant to a doctor's appointment is honestly mind blowing to me. So is the notion of applying design principles to the patient's experience.

[Tom Lee]
If you really care about the individual as a patient, and you really want to be the best doctor, you do care about the experience.

[Mio Adilman]
As amazing a notion as this is, at the time, let's say early to mid nineties, Tom Lee was a young doctor just getting into medicine. It's not like the massive American healthcare system was asking for his input.

[Tom Lee]
So, that catalyzed basically a role of the dice. A buddy of mine said, "Hey, you're as smart as some of the CEOs I work with, why don't you just go to business school?" And I was pretty naïve. I was an academic clinician, pretty heavily steeped in a research oriented institution with no understanding of economics or technology.

[Mio Adilman]
In just a moment a primary care physician with the heart of a designer roles the dice on getting an MBA, so he can basically take on the healthcare system.

But first, if you're as obsessed about great customer experience as I am, new episodes of Repeat Customer post every two weeks. In between episodes you can learn more at Zendesk.com/RepeatCustomer, or you can post a review to let us know what you think of this podcast experience, and if you're a CX professional looking to elevate your company's customer service game, check out Zendesk.com, because the best customer experiences are built on Zendesk.

Tom Lee became a doctor to help patients, but he found the system was blocking him from giving them a pleasant customer experience, so he decided to do something about it.

[Tom Lee]
I had a design vision for what a modern doctor's office might look like, and I knew it had to be in primary care, because we were under investing as a system in primary care. So it not only would be a better patient experience, but it would also reduce total cost of care, and really provide a better experience for the healthcare system. Fortunately, I was lucky enough to get into Stanford. I knew that was the place that I needed to go to develop an entrepreneurial tech oriented backbone.

[Mio Adilman]
Technology was key to Dr. Lee's plan.

[Tom Lee]
I didn't know exactly how it was going to work.

[Mio Adilman]
He'd gotten a taste of it during his resident days at the Brigham and Women's hospital in Boston.

[Tom Lee]
I could see the potential of how tech would transform information flows, which is what the vast majority of medicine is, and also how people worked together as teams.
[Mio Adilman]
But keep in mind, this was the late ‘90s.

[Tom Lee]
Looking back it's easy to forget, but Yahoo! was just a new website, barely anybody had email, and bandwidth was modem. So yeah, in hindsight that does look a little bit odd, but yeah, I knew that a lot of the repetitive stuff that was going on could be automated and simplified.

[Mio Adilman]
So, Tom started by creating a company called Epocrates. It was, and still is, a mobile medical reference app for doctors. They use it to check dosing instructions, diagnoses, medical news, stuff like that.

[Tom Lee]
This dates us, I mean it was in the era of the Palm Pilot, yeah. But we were proof that...Before then everybody was saying, "Doctors don't adopt technology, they're just risk-averse." I'm like, "No, if you design something valuable for a physician, they'll adopt the product."

[Mio Adilman]
Tom had used technology to optimize part of the healthcare experience. Making doctors jobs a bit easier was also good for the patient, but it was a relatively small step compared to his next challenge. Remember, the goal was totally re-imagining a broken system by creating a customer experience where one hadn't really existed before.

[Tom Lee]
The thesis of One Medical was, you've got to start from scratch, you've got to build something clean state, because you don't have all this legacy stuff, and allow something new to grow. So literally almost every aspect of our business operations was reexamined with a customer orientation and/or an operational labor efficiency orientation, so that we could build a higher-touch experience at lower cost.

[Mio Adilman]
In addition to a bunch of tech applications, which we'll get into more in a couple of minutes, Tom was also focused on design and operational optimization to improve the overall customer experience.

Let's start with the physical design. As Erika Heald described at the beginning of the show, the waiting rooms and exam rooms are comfortable, almost like living spaces.

[Tom Lee]
It was an important feature that was, frankly, under recognized by most clinicians. Most clinical offices just don't have that aesthetic, that you're shocked that this is deliberate. So all these really expensive, ugly linoleum cabinets that are in every single exam room, why do they exist? They're always empty. And so we got rid of all that stuff. So, it was important from day one, obviously, because we felt like the environment in which you greeted the patient was also an important signal on whether they could trust, be open, and feel like you were running a clean operation.

[Mio Adilman]
And when Tom says greeted the patient, he actually means the doctor, not a nurse or assistant, comes into the waiting lounge to get you.

Hi, how are you?

[Navya Mysore]
I'm good, how are you?

[Mio Adilman]
Very good. Thank you for seeing me on such short notice.

[Navya Mysore]
Yeah, of course, it's nice to meet you. So, we are walking down the hallway, down to my office. Generally...

[Tom Lee]
So why not do that? Sure, it costs an extra 30 seconds of the doctor's time, but it was better for the patient, better for the doctor. The doctor wants to catch up and see how things have been going, and you don't need to pay for somebody to bring the person back to the exam room.

[Mio Adilman]
This leads us to operational cost savings.

[Tom Lee]
When you go to an average doctor's office, even still today, there's a person that checks you in, you're writing out a paper based form for maybe the second or third time, and somebody else might weigh you, and then somebody else might come and do a pre-interview, and then you finally see the doctor for five minutes, and then you go and see somebody else as a checkout process. So, when I started to think about the math of that, it just seemed like a lot of people to just really bring the patient back to the exam room.

[Tom Lee]
It was shockingly simple. We built a website where you could register online, you would book a same day appointment, and we'd have more time than an average doctor, and in those days I did everything.

[Mio Adilman]
One Medical launched in 2005 with one clinic in San Francisco.

[Tom Lee]
So then I'd do the blood draw, and I'd follow up, and it was true one-on-one personalized care. I knew some of these systems would scale up differently, but I knew from my patients’ responses they were very happy with the model. It was gratifying to see that, and then also gratifying to see that you can make the economics work, contrary to what everybody had told me about starting a new healthcare model that was solo at the time, in a downtown high real estate rental market.

[Mio Adilman]
How many patients do you see on average now?

[Navya Mysore]
I would say, on a typical day, 16 to 18 patients.

[Mio Adilman]
I've come to One Medical's Tribeca clinic in Manhattan with an appointment with Dr. Mysore, that doctor who used to see 30 to 45 patients a day.

[Navya Mysore]
Definitely significant amount of time that is really allowing us to spend more time together. You know 40 minutes, 45 minutes in the office now with the patient, specifically depending on what they're coming in for.

[Mio Adilman]
More time with a doctor is a key part of this new customer experience, because it has health benefits. Current One Medical CEO, Amir Rubin, says it makes the time to create a holistic health plan.

[Amir Rubin]
It's giving them time to dig in deeper. Sometimes we'll be in the middle of an appointment, and it won't be till midway, or even towards the end of it, we sometimes laugh and we call them door handle questions. You've been there the whole time, but the patient's got their hand on the door handle and they're like, "Well, I've got one more thing." And that was the thing.

[Mio Adilman]
But you don't just get more time with a doctor by having them greet you in the waiting room. The real reason why this works is because in addition to billing your insurance for actual medical procedures, One Medical charges you an annual subscription fee, $200 a year. Remember Tom Charland, the guy who explained the economics of healthcare to me at the beginning of this? He said it was an insurance driven fee for service model that was the key limiter to a good patient customer experience.

[Tom Charland]
In the new model, One Medical, you're paying a membership fee, and part of that membership fee essentially covers these little, tiny, nitty gritty things that you need to get done. If you just have a question for a doctor, you can email them. And they, through that membership fee, they consider themselves to have already been paid for that activity, and it's no problem. All of a sudden they're really just practicing medicine, they're really just caring for patients, as opposed to literally at the same time having to worry about the economics.

[Mio Adilman]
And this is what really frees up the doctor's schedule, and the added time they spend with patients means less visits to expensive specialists.

[Tom Charland]
And it's called referral management. So, we're going to start to see these new medical groups emerge where the employers are willing to pay the membership fee on behalf of the patient in order to get better primary care, in order to cut off the downstream revenue to specialists.

[Mio Adilman]
But it isn't just what happens during clinic hours that's covered by your membership fee.

[Amir Rubin]
The other nice thing about our model is we recognize that the encounter doesn't have to start and end in the office visit. So we can greet the member on their terms.

[Tom Charland]
Virtual medicine, just accessing the technology platform, it's a whole new mindset that you're a member, and included in that membership is this platform.

[Mio Adilman]
And that brings us back to the technology piece. That key thing founder Tom Lee envisioned would be the real game changer in a new healthcare customer experience. Here's a quick story to illustrate what that experience can look like. Erika Heald, the patient we heard from at the very beginning, the one who likes One Medical's beautiful waiting rooms, well, she's kind of danger prone.

[Erika Heald]
For example, there was one time when we were going to go to the Outside Lands music festival, and we were on our way, out the door, and I slipped on something in the bathroom and I jammed my finger really, really hard and it got all swollen and horrible.

[Mio Adilman]
But the Outside Lands festival is a three day party.

[Erika Heald]
They are very expensive tickets, and I was just beside myself about what was I going to do. I didn't want to take out time to go and make an appointment or go sit in the ER.

[Mio Adilman]
That would have taken most of a whole day. So Erika did both at the same time. She went to the doctor and the festival together.

[Erika Heald]
I took the call from them literally at the bus stop by the festival, a live video call with a doctor, and took a look at it, went through all the diagnostics, and determined that I just needed to ice it, and that it would be okay, and that if it got worse by the next day, then I could come in. And so it basically saved me from ruining and missing out on my festival.

[Kim MacPherson]
I think generally One Medical has really picked up on this desire to have medical care, primary medical care look a little bit more like other things that we're able to do on our terms; book a ride, get a table at a restaurant, book airfare, ask questions of experts.

[Mio Adilman]
Kim MacPherson researches and teaches health management and innovation at UC Berkeley.

[Kim MacPherson]
One Medical, from a member perspective, utilizes an app. I can email in a secure way back and forth with my primary care provider, or the care team, so if I want to alert that provider to something, or ask a question, I don't need to make an appointment, I don't need to make a phone call. They can also use that channel to send me referrals, I can order medication refills, or check on refills, be alerted that test results are available or a prescription is available. I can also schedule appointments very seamlessly that way, and based on who I want to see and the type of need that I have, the app leads me pretty carefully and seamlessly through almost a triaging mechanism.

[Mio Adilman]
The app also sends post-consultation follow ups and reminders for recurring exams, all great for patients. And for doctors, new tech advances can relieve even more of the workload.

[Amir Rubin]
We're starting to use interesting machine learning-type approaches, for example. I might message my provider. Well, my provider's in clinic all day. Well, this machine learning looks at my message and says, "Hey, Amir has a question about a referral, or an authorization, or a retained prescription renewal." It can then take that message out of my providers queue, and we've set up teams of staff, whether it's registered nurses, or nurse practitioners, or virtual physicians who can answer those questions, because I don't need to wait for my provider, at the end of the day, to do this. So we'll often get responses in minutes.

[Mio Adilman]
The AI sends requests and assigns jobs to a decentralized unit, so care is available 24 hours a day, and it's seamless, which points to what primary care might look like in the future.

[Kim MacPherson]
It's a tired analogy, but this idea of ATM. I have a bank affiliation, but I can use ATMs around the world, and they know who I am, they know how much money I have, and I can engage with them as I wish. I think that we'll need to get to that place in healthcare to meet the needs.

[Mio Adilman]
What Kim MacPherson at UC Berkeley means is that even the old patient primary care physician relationship might be changing.

[Kim MacPherson]
There's a question of will the construct of a primary care assignment be relevant that far out, or will you be knitting together these different tech interactions, so that there is a coherent seamless record of what you're doing, so that anybody that needs to engage with you can, and that's why the experience every time matters. You don't actually want to rely on, "If I see Dr. Bob, I have a great experience, if I see Dr. Joe, it's less so." That's why you need that standard consistent wonderful engagement experience every time, and places like One Medical can really use their technology, and kind of the uniformity of the high level of experience that they put out there to create that bond, so that you don't want to go anywhere else.

[Mio Adilman]
And more and more people are choosing to do just that. One Medical now has over 60 locations in nine major cities. They aren't the only company offering what you could call an omnichannel healthcare customer experience. There's a growing number of clinics using tech, there's also retail clinics in places like CVS that offer street level access to doctors, and urgent care clinics are starting to emphasize primary care, which is great for us. But One Medical was one of the first to reject the status quo, and really identify the need for a totally new customer experience for patients, to apply design principles both physical and technological, and to map the patient's journey.

[Mio Adilman]
Just as they try to give patients a holistic level of healthcare, they're looking at the healthcare system holistically. Remember, the healthcare system in many ways is the real patient here.

[Amir Rubin]
We have demonstrated we could take out 10% of the U.S. healthcare spending with our model, because we're avoiding emergency visits, we're not sending unnecessary referrals. We can start nudging people to manage chronic diseases, or prevent those conditions from developing into full blown diseases.

[Mio Adilman]
Most of the companies we look at on Repeat Customer have, in some way, disrupted their respective industries with a customer focused approach. You could call one medical a startup, but they still operate completely within a rigid traditional industry, and some of those limits are necessary for regulatory reasons. I mean, these are people's lives we're talking about. So, this disrupting from within is almost more impressive. In the next episode, we're going to talk about a legacy company that went outside their traditional industry of theme parks to provide their fans with a new customer experience on the high seas. I'm talking about Disney Cruises. Until then, thanks for listening.