For the past decade or so, Portland, Oregon-based Zoom+ has been innovating around a simple idea: an integrated health system you can control with your phone. But developing that idea into a business has exposed CEO and cofounder Dr. Dave Sanders and his team to a number of challenges, many of which Sanders spoke about in his address at MobiHealthNews 2016 last week.

The genesis of the company, Sanders said, was thinking about the millennial customer and their particular healthcare needs. Assessing those needs, he said, they realized the only way to serve that customer would be to provide “full stack” healthcare: to be the patients’ primary care provider, specialist care provider, and emergency room, all in one. And all that care would be mediated through, and when appropriate delivered through, the phone.

“We, like many of you, believe that in the ensuing decade over three-quarters of my care hours will be experienced over my phone,” Sanders said. “So for the first layer of care, with Zoom+, we’re trying to build a robust layer of self-care, social care, and telecare. And we are increasingly doing that. We can show in our own data that people are moving systematically toward self, social, and digital care. When they need more than that, the system then routes them to one of our 20 neighborhood clinics, which we have across the Portland area. And if they need more than that, they can go to one of three paths. They can go to our adult and child primary care services, they can go to our own on-demand specialist services, or they can go to our on-demand ER. All on-demand, all controlled with your phone.”

As they developed the “full stack” experience, Sanders said, they realized they also needed to be their patient’s health insurer.

“As entrepreneurs, one of the challenges I think that we deal with, that we’ve tried to overcome, is that it’s very hard to get your application, to get your product, into the healthcare economic slipstream. Because it’s a very narrow slipstream in a lot of ways,” Sanders said. “So my question was how do you get yourself in the middle of that slipstream, without being captives of insurers, captive of large systems? That’s why we decided to control our own destiny by creating our own insurer. People ask us, why would you go through all the trouble, all the pain? We wanted to control our own future. And that means being able to sell directly to businesses, governments, individuals, and control that full stack if we wanted to. We had to make sure we had access to the economics to do the innovation that we want to do.”

But that approach quickly put the company into conflict with local regulators. Sanders told a story about Oregon regulators telling the company they couldn’t use the word “emergency” to describe their emergency services. After much pressing, the regulator admitted that the problem was “the hospitals don’t like it”. 

In another anecdote, he said that the local health insurance commissioner responded to a lengthy proposal for “The world’s first health plan that you control with a phone” with the comment, scrawled in the margins, “does that include landlines?” When they responded that it didn’t, the commissioner said they couldn’t use that slogan.

“At every turn, as we’re all trying to innovate and change that world, we’re going to face these kinds of forces that are going to say ‘not so fast, not so fast, not so fast,’” Sanders said. “So the challenge is how we can push the innovation, but also create context and frameworks for change in a society that’ll keep pushing back on us.”

As of May Zoom's health plan counted about 2,500 members. Sanders said some 400,000 people in the Portland area are regular users of its various care facilities and services.

Critics of Zoom+ have pointed out that by focusing on millennials (average patient age is 34) so squarely, the company creates a risk pool that’s comparatively easy to manage and removes healthy people from other insurers’ pools. But Sanders defends the idea of focusing services on a particular segment of the population.

“You know I was raised classically in medicine where the noble thought was to be all things to all people. I think that core noble thought is at the heart of our failings as a healthcare system,” he said. “…So let’s create products that are focused on populations, that’s ok. This may seem like a negative thing but within 10 years it’ll all be changed over.”