Temple of Zoom

Dave Sanders wants his clinics to provide insurance. The state said the policies cost too little.

"Cellular immortality coaching?" asks a large billboard on the east side of the Willamette River. That's all the blue and white sign says, other than the name of the company that purchased it, Zoom+ Performance Health Insurance.

It's a cryptic ad for a company that state regulators still find inexplicable.

ZoomCare started in 2006 by putting on-demand neighborhood health clinics throughout Portland. Today, it has 21 clinics in the Portland metropolitan area and Salem and six in Seattle.

Appointments start on time—in fact, if patients are more than five minutes late, they have to reschedule. Exam rooms have flat-screen TVs on the wall showing patients their medical history, diagnosis and treatment plan. But don't expect to see a doctor: Most examinations are conducted by a nurse practitioner.

In 2014, ZoomCare announced that it would be getting into the insurance business. Last May, it rebranded itself as Zoom+, and announced plans for surgery, mental health services, fitness coaching, parenting specialists, “brain training” and dental cleaning. 

The company was soon engaged in a lengthy pricing dispute with the Oregon Insurance Division. But not for the reasons you might think.

In a dispute that has few precedents in Oregon, the state insurance division argued that Zoom+'s proposed rates were too low and forced the company to increase them.

Dave Sanders, the youthful, energetic physician-turned-entrepreneur who cofounded Zoom+ with Dr. Albert DiPiero, says that this is because the state really doesn't understand the innovation of his business model, one that uses fewer physicians and more nurses, expands the use of telemedicine and relies on a health care protocol called "Right Care" that decreases the use of unnecessary and expensive tests. In a letter of support, advocacy group OSPIRG encouraged the competition: "Zoom Health Plan, a new market entrant, is proposing a new model of health care delivery specifically intended to manage utilization and contain costs."

But the Insurance Division suggests those rates may be too low to cover patients' costs. "We have proposed increased rates," says Insurance Commissioner Laura Cali, "in order for consumers to continue counting on the coverage they have purchased." The agency declined further comment for this story.

Sanders successfully fought to change state rules—especially so its insurance can cover off-site doctors treating patients via computer and phone.

State Sen. Elizabeth Steiner-Hayward (D-Portland) says Zoom+ came to her in 2013, when it was seeking to require insurance companies to cover more expansive telemedicine treatment. Steiner-Hayward says before the changes, "insurance only had to reimburse telemedicine services if it was not possible for the person to receive care otherwise" and if the services were administered at a medical facility.

“They’re trying to set up a different model, which always takes work,” she says. 

The use of telemedicine will help Zoom+ keep its costs down, says Susan King of the Oregon Nurses Association. "It breaks down barriers," she says, "and those barriers have a cost attached."

Zoom+ also lobbied for the passage of a bill to allow nurse practitioners to dispense limited doses of medication to patients. The use of nurse practitioners is another way that Zoom+ says it can reduce costs for customers.

Sanders (who will be speaking at TechfestNW in August) recently sat down with WW to discuss Zoom+.

WW: Can you give us the origin story of ZoomCare?

Dave Sanders: Dr. DiPiero and I met the first year of college, at Michigan. But we both were the same kind of people, who had always wanted to be physicians. We went all the way through our training and we get out into the world and we find, "Oh my gosh, health care can't be this dysfunctional, can it?" It can't really work this way, between the providers and doctors and insurers with the battling going on. So we thought we could create enterprises that could help solve that problem. So we spent about 10 years after our training founding two companies here in Portland, and ultimately sold those companies, and felt dissatisfied by that.

Go back to 2006, when you first began ZoomCare. How do you persuade a physician to come work for you?

It was very hard. At one point, no one would work for us. And then one day, a young physician walked into our doors, and he was able to translate the concepts we had and make it a reality. People began saying, "Have you seen what they're doing?" Doctors became interested in it. But even then, we had this saying: performance not pedigree. I was raised in the pedigree-based world, where my title, my degree, my university was what mattered. And we began to find that team-based care, and systems of care, really drives the results. A well-trained physician's assistant or nurse practitioner can do an equal or better level of care.

How are you able to offer health care at substantially lower prices?

When you come into Zoom, you will be entering a system of care. You will typically be seeing a physician's assistant or a nurse practitioner. They're practicing in neighborhood clinics that are a thousand or so square feet. We take those savings and we pass that along. We have been the radical pushers of telemedicine. When you use PAs and NPs for your front line, radically use telemedicine, have your own ER that's not rewarded for admissions, we have changed the entire cost structure. We focus on reducing excess utilization, excess unit pricing and excess [insurer-provider] friction.

What do you specifically do to reduce excess utilization?

We have a concept called Right Care. And Right Care asks, what does the science say about this? And the Right Care is no more, and no less. So structurally, we have built into our own home-built software systems guidelines that say, if you want to work up this headache, here's how you work it up. And it's a menu. Here's how you work it up. And here is when and only when you get to the level of MRI (magnetic resonance imaging, an expensive diagnostic test that some critics say is overused). And if you order an MRI prematurely, it will flag, and we have an internal system for authorization. 

In Oregon, there are network insurers and delivery-system insurers. Kaiser is the only other delivery-system insurer. How does its model compare to yours?

Well, Kaiser is a phenomenal company. They do a great job at what they do. What we share is that by having our own provider organization, our own people, we have a team-based care model. And I think team-based care companies are better able to organize their standards, what we agree upon, and reward internally for that. And we can reduce extra testing and hospitalizations. We can reduce some of those things by working off one shared platform. So that's where we're similar. Where we're different, though, is different people, different processes, different methods of payment. We are practicing in neighborhood clinics that are a thousand or so square feet, that are not made from marble and waterfalls, so it's a lower-cost physical plan we're working off of. Kaiser may be working at the same price point, but frankly, we're breathing a lot less heavy.

So you want your insurance prices to be as low as possible in a competitive marketplace.

Well, no, not actually as low as possible. What we would like is for the price not to be a barrier for purchasing. The product has trade-offs for the public. The trade-off you're making as a consumer is, you're not getting a choice of 5,000 providers and hospitals. You're going to pick Zoom. It's branded care versus generic care. And it should be a beautiful, designed experience for you. We're going to control that experience, and we can control the costs better.

Is it a disadvantage that you're a for-profit company working in an industry that is mostly nonprofits?

Because they’re not paying taxes, because they have access to capital, that kind of stuff? It is. I was giving a talk, and someone said to me, “Dr. Sanders, it concerns me that you’re not a nonprofit.” And I said, the CEO and president of Providence made $4.5 million last year. They’re not nonprofits. They’re the highest-paid people in the game. That’s why you’ve got to have different people, you’ve got to build different types of places and build your own technologies. We’ve got to fundamentally change dynamics so we can have a spot in the marketplace and in the world. 


Dave Sanders' enthusiastic style is marked by his fondness for slogans and phrases that try to capture his health care model. Here are a few buzzwords he dropped during our interview:

cloud care: The use of telemedicine through smartphones and computers. Patients access care “in the cloud.”

the four P's:  The things Zoom+ approaches differently from other health care providers—people, places, processes, payment.

the full stack: Used by Sanders in a variety of contexts, it means a complete health care delivery system.

performance not pedigree: The motto behind Zoom+'s belief that licensed physicians are often overused in traditional health care systems.

Sarah: The name for Zoom+'s imagined composite customer.

the Sarah Seven: The needs Zoom+ has determined are important to its target customers but are not met by other health care providers.

twice-half-10: Zoom+'s mantra, meaning twice the health, half the price, 10 times the customer delight.

10 by 10/1: Zoom+'s goal to do 10 big things by Oct. 1 of this year.

urgent emergent: â€œComplete, get-you-back-in-the-game care”; the Zoom+ neighborhood clinics currently in existence. 

WWeek 2015

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