In Part 1 of this series, I explored the need to reframe our approach around “social determinants of health.” In order to improve individual lives, our approach must look at risk factors, and it must include a mechanism to uncover what matters most to the individual. 

Risks are important as they convey an individual’s context, but they don’t tell us the full picture. They don’t tell us the progress people seek. If we want to improve health, and people’s lives as a result, we must understand the causal mechanisms behind their outcomes. We must understand what progress they desire. Then we can build solutions to enable that progress.

As Edwards Deming said, “every system is perfectly designed to get the results it gets.” Our health care system is currently designed to talk about social determinants, ask about social risks, and thus it fails to effectively address individual needs and jobs to be done. 

On the pathway to a new system of health and care, providers and payers can learn from innovators that have reinvented their business models to focus on the consumer and the progress they seek. Business models rooted in understanding individuals’ jobs to be done embody three key characteristics: 

  1. Processes are in place to understand the individual’s context – that is, the situations in which they live, eat, work, and play; and 
  2. Processes exist to uncover what matters to the individual; and
  3. The organization’s measures of success are at least partially defined by how the individual defines success

These three characteristics are executed on top of a basis of trust, and a robust foundation of data that drives knowledge and actionable insights. 

Oak Street Health’s processes are designed to understand the consumer’s context 

Oak Street’s care and business models provide an excellent example of an organization that deeply understands their consumers’ contexts. Key business model components enable them to understand a patient’s context and desired progress (i.e. their job to be done) and match services to that job. 

For example, one key process that enables this patient understanding is Oak Street’s visit length. Instead of the typical 15-minute primary care visit, providers spend 80 minutes with their new patients over two visits in their first month of membership. This allows Oak Street providers to deeply understand their patients’ contexts and needs, which is not possible in 15 minutes. Their model supports continued interaction as their providers see a maximum of ten patients per day instead of the 20+ patients expected in a traditional primary care model. They are also supported by a robust care team. 

Oak Street’s model has helped their patients, who are predominantly Medicare patients with multiple chronic conditions, enhance their life quality. Since opening in 2012, Oak Street has reduced hospital admissions and ER visits by 51%, while maintaining a net promoter score (NPS) of 90. For reference, the NPS of traditional primary care in 2019 was -1.2. Yes, it was actually negative. While NPS is not the ideal metric to convey what matters most to the patient, it’s undeniable that 51% fewer visits to the ER is an improvement to an individual’s quality of life. 

Factor Health learns what matters to the consumer and designs programs to achieve their desired progress

Factor Health is changing the way we think about health and care. It is not a typical payer or provider. Instead, it partners with payers, providers, and community organizations to deliver health interventions outside of doctors offices and hospitals. 

To demonstrate near-term cost savings and health improvement, Factor focuses on addressing individual or family risk factors – such as nutrition insecurity and loneliness – for the under and uninsured. Interventions are less than one year in length and seek to demonstrate an ROI in less than two years. Perhaps most importantly, Factor Health designs programs around the individuals’ desired progress, in concert with the payer’s or customer’s desired progress to reduce health care costs. 

For example, Factor Health recently led a call program to address loneliness, depression, and anxiety in food-insecure older adults. The program leveraged 16 laypeople to have empathetic phone conversations with older adults, on a cadence determined by the consumer. Factor’s founder summarizes their approach as follows, “The focus of the calls were for the caller to learn about the other person and to prioritize whatever it was that the person they were calling wanted to prioritize…The bottom line is, you’re listening as much as possible.” 1

By focusing on what mattered to the individual, participants saw significant reductions in loneliness, depression, and anxiety scores. Most importantly, Factor Health received feedback from consumers that the calls made them happy and motivated. In short, the program helped individuals achieve some component of their desired progress, in a short amount of time, at a low cost. You can learn more about the approach and recent outcomes from the Health Affairs presentation Factor’s founder recently shared. 

While our national system of health and care is in the early stages of transformation, innovators are already making an impact by improving the amount of life in people’s years, not just their years in life. Health care is historically slow to evolve. As we transform our system of health and care, let’s help ourselves speed up by learning from those who have redesigned their care and business models around the individual’s desired progress. If we do, we’ll all live better lives as a result. 

1. Empathetic phone calls reduce loneliness, depression in older adults. May 28, 2021.


  • Ann Somers Hogg
    Ann Somers Hogg

    Ann Somers Hogg is the director of health care at the Christensen Institute. She focuses on business model innovation and disruption in health care, including how to transform a sick care system to one that values and incentivizes total health.