Professor Enthoven: Integrated delivery systems

INTEGRATED DELIVERY SYSTEMSINTEGRATED DELIVERY SYSTEMS

PRESENTATION TOPRESENTATION TOTHE NUFFIELD TRUSTTHE NUFFIELD TRUST

MAY 14, 2008MAY 14, 2008

HALLMARKS OFHALLMARKS OF INTEGRATED SYSTEMS IINTEGRATED SYSTEMS I

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SHARED VALUES & GOALSSHARED VALUES & GOALS••

ALIGNMENT OF INCENTIVES; ALIGNMENT OF INCENTIVES; COMMON REVENUE STREAMCOMMON REVENUE STREAM

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PHYSICIAN LEADERSHIPPHYSICIAN LEADERSHIP••

A MANAGEMENT STRUCTUREA MANAGEMENT STRUCTURE

HALLMARKS OF HALLMARKS OF INTEGRATED SYSTEMS IIINTEGRATED SYSTEMS II

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COMPREHENSIVE RECORDSCOMPREHENSIVE RECORDS••

SHARED PRACTICE GUIDELINESSHARED PRACTICE GUIDELINES

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ALL OR MOST OF A PATIENTALL OR MOST OF A PATIENT’’S S CARE WITHIN A SYSTEMCARE WITHIN A SYSTEM

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PATIENT CENTEREDPATIENT CENTERED••

CULTURE OF TEAMWORKCULTURE OF TEAMWORK

HALLMARKS OFHALLMARKS OF INTEGRATED SYSTEMS IIIINTEGRATED SYSTEMS III

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INTEGRATION ACROSS SETTINGSINTEGRATION ACROSS SETTINGS••

POPULATION MEDICINEPOPULATION MEDICINE

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PERSONAL AND PUBLIC HEALTH: PERSONAL AND PUBLIC HEALTH: EMPHASIZE HEALTH PROMOTION EMPHASIZE HEALTH PROMOTION & DISEASE PREVENTION& DISEASE PREVENTION

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SOMATIC AND MENTAL HEALTHSOMATIC AND MENTAL HEALTH

BENEFITS OF INTEGRATED BENEFITS OF INTEGRATED SYSTEMSSYSTEMS

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HEALTH PROMOTION, DISEASE HEALTH PROMOTION, DISEASE PREVENTIONPREVENTION

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EFFICIENT RESOURCE USEEFFICIENT RESOURCE USE••

BETTER OUTCOMES?BETTER OUTCOMES?

vsKP NCal hospitals . all other hospitals in counties with KP hospitals

Source: OSHPD

0

5

10

15

20

25

8%

13%

KP THE REST

= statistically sig. p<0.01

3030--Day Mortality After Acute Heart AttackDay Mortality After Acute Heart Attack

BENEFITS OF INTEGRATIONBENEFITS OF INTEGRATION

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ACCOUNTABILITY; LEADERSHIP IN ACCOUNTABILITY; LEADERSHIP IN PUBLICLY REPORTED QUALITY PUBLICLY REPORTED QUALITY MEASURESMEASURES

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CONVENIENCE AS IN CONVENIENCE AS IN ““ONE STOP ONE STOP SHOPPINGSHOPPING””

AND AND ““SAME DAYSAME DAY””

OPEN OPEN

ACCESS. PATIENTS FEEL THE ACCESS. PATIENTS FEEL THE ““SYSTEMNESSSYSTEMNESS””

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LEADING IN APPLICATION OF LEADING IN APPLICATION OF INFORMATION TECHNOLOGY FOR EHR, INFORMATION TECHNOLOGY FOR EHR, PATIENTSPATIENTS’’

CONVENIENCE AND CONVENIENCE AND

CAREGIVER SUPPORT TOOLSCAREGIVER SUPPORT TOOLS

INTEGRATION IS A MATTER INTEGRATION IS A MATTER OF DEGREEOF DEGREE

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EVEN THE MOST INTEGRATED (KP EVEN THE MOST INTEGRATED (KP IN CA) REFER SOME CARE TO IN CA) REFER SOME CARE TO SPECIALIZED REGIONAL CENTERSSPECIALIZED REGIONAL CENTERS

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SOME INTEGRATE CARE BUT NOT SOME INTEGRATE CARE BUT NOT FINANCESFINANCES

Integrated Care: how many Integrated Care: how many patients in the USA?patients in the USA?

Common Revenue StreamsCommon Revenue StreamsKaiser PermanenteKaiser Permanente

8.7million8.7million

Veterans Administration 5.7Veterans Administration 5.7Other PGP 4.5Other PGP 4.5Multiple Revenue StreamsMultiple Revenue StreamsIntermountain Healthcare 1.0Intermountain Healthcare 1.0““California Delegated HMOs 9.0California Delegated HMOs 9.0Other Large MSGP 10.0Other Large MSGP 10.0

““California Delegated HMOsCalifornia Delegated HMOs””

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Medical Groups paid per capita for Medical Groups paid per capita for professional services by insurance professional services by insurance companies.companies.

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Have poor incentives alignment. Have poor incentives alignment. Hospitals, Medical Groups, and Hospitals, Medical Groups, and Insurance Companies have conflicting Insurance Companies have conflicting objectives and interests.objectives and interests.

WHY DONWHY DON’’T WE HAVE MORE T WE HAVE MORE INTEGRATED SYSTEMS IN THE USA?INTEGRATED SYSTEMS IN THE USA?

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ORGANIZED MEDICINE IN THE USA ORGANIZED MEDICINE IN THE USA CONDUCTED A BITTER WAR AGAINST CONDUCTED A BITTER WAR AGAINST THEM UNTIL RECENT YEARS.THEM UNTIL RECENT YEARS.

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MOST EMPLOYERS DO NOT OFFER THEM MOST EMPLOYERS DO NOT OFFER THEM AS COST CONSCIOUS CHOICESAS COST CONSCIOUS CHOICES

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OFFERING CHOICES DOESNOFFERING CHOICES DOESN’’T FIT MANY T FIT MANY EMPLOYERSEMPLOYERS

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INSURANCE COMPANIES RESIST INSURANCE COMPANIES RESIST CONSUMER CHOICE OF PLANCONSUMER CHOICE OF PLAN

THE TRADITIONAL THE TRADITIONAL FRAGMENTED SYSTEMFRAGMENTED SYSTEM

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““FREE CHOICEFREE CHOICE””

OF DOCTOROF DOCTOR••

““FREE CHOICEFREE CHOICE””

OF TREATMENTOF TREATMENT

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FEEFEE--FORFOR--SERVICE PAYMENTSERVICE PAYMENT••

DOCTORDOCTOR--PATIENT NEGOTIATION PATIENT NEGOTIATION OF FEESOF FEES

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SOLO OR SMALL SS GROUP SOLO OR SMALL SS GROUP PRACTICEPRACTICE

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PHYSICIAN AUTONOMY CULTUREPHYSICIAN AUTONOMY CULTURE

HOW COULD AMERICA GET MORE HOW COULD AMERICA GET MORE INTEGRATED CARE?INTEGRATED CARE?

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““OPEN THE MARKETS AND LEVEL THE OPEN THE MARKETS AND LEVEL THE PLAYING FIELDPLAYING FIELD””

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UNIVERSAL COVERAGE BASED ON UNIVERSAL COVERAGE BASED ON PRINCIPLES OF MANAGED PRINCIPLES OF MANAGED COMPETITIONCOMPETITION

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THE DUTCH HEALTH INSURANCE THE DUTCH HEALTH INSURANCE MARKET COMBINED WITH AMERICAN MARKET COMBINED WITH AMERICAN INTEGRATED DELIVERY SYSTEMSINTEGRATED DELIVERY SYSTEMS

Elements of Managed CompetitionElements of Managed Competition

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““EXCHANGEEXCHANGE””

OR MARKET ORGANIZEROR MARKET ORGANIZER••

INFORMED, COST CONSCIOUS, INFORMED, COST CONSCIOUS, CONSUMER CHOICECONSUMER CHOICE

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INDIVIDUAL (NOT GROUP) CHOICEINDIVIDUAL (NOT GROUP) CHOICE••

RISK EQUALIZATIONRISK EQUALIZATION

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GUARANTEED ISSUE, COMMUNITY GUARANTEED ISSUE, COMMUNITY RATINGRATING

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LEVEL PLAYING FIELDLEVEL PLAYING FIELD••

PRICE ELASTIC DEMANDPRICE ELASTIC DEMAND

HOW COULD THE NHS GET TO HOW COULD THE NHS GET TO INTEGRATED CARE?INTEGRATED CARE?

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“…“…POLICY MAKERS NEED TO POLICY MAKERS NEED TO RESIST THE TEMPTATION TO RESIST THE TEMPTATION TO PRESCRIBE A SINGLE APPROACH PRESCRIBE A SINGLE APPROACH AND TO FOCUS INSTEAD ON AND TO FOCUS INSTEAD ON ENCOURAGING THE ENCOURAGING THE DEVELOPMENT OF INTEGRATED DEVELOPMENT OF INTEGRATED CARE USING THE MEANS THAT CARE USING THE MEANS THAT APPEAR MOST APPROPRIATE IN APPEAR MOST APPROPRIATE IN DIFFERENT CONTEXTS.DIFFERENT CONTEXTS.””

C. HAMC. HAM

MORE WISDOM FROM THE MORE WISDOM FROM THE MASTERMASTER……

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““

PRIMARILY [INTEGRATION] IS PRIMARILY [INTEGRATION] IS ABOUT RELATIONSHIPS BETWEEN ABOUT RELATIONSHIPS BETWEEN PEOPLE. THESE RELATIONSHIPS PEOPLE. THESE RELATIONSHIPS ARE NOT INFORMAL FRIENDSHIPS. ARE NOT INFORMAL FRIENDSHIPS. THEY HAVE TO BE WORKED ON THEY HAVE TO BE WORKED ON AND BUILT PROFESSIONALLY IF AND BUILT PROFESSIONALLY IF CLINICAL INTEGRATION IS TO BE CLINICAL INTEGRATION IS TO BE MEANINGFUL AND SUSTAINED MEANINGFUL AND SUSTAINED THROUGH GOOD AND BAD TIMES.THROUGH GOOD AND BAD TIMES.””

IDS IN NHS?IDS IN NHS?

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ENCOURAGE EMERGENCE OF ENCOURAGE EMERGENCE OF INTEGRATED SYSTEMS, BASED ON INTEGRATED SYSTEMS, BASED ON NETWORKS OF LIKENETWORKS OF LIKE--MIINDED GPs MIINDED GPs WORKING TOGETHER TO PROVIDE WORKING TOGETHER TO PROVIDE AND COMMISSION CARE FOR THE AND COMMISSION CARE FOR THE POPULATIONS THEY SERVE. USE POPULATIONS THEY SERVE. USE BUDGETS TO INCLUDE SECONDARY BUDGETS TO INCLUDE SECONDARY CARE SPECIALISTS.CARE SPECIALISTS.

IDS IN NHS?IDS IN NHS?

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TOTAL PURCHASING PILOTS WERE TOTAL PURCHASING PILOTS WERE A GOOD DEVELOPMENT, GROWING A GOOD DEVELOPMENT, GROWING ORGANICALLY OUT OF ORGANICALLY OUT OF INDIVIDUAL FUNDHOLDERS. TOO INDIVIDUAL FUNDHOLDERS. TOO BAD THEY WERE NOT ALLOWED TO BAD THEY WERE NOT ALLOWED TO CONTINUE AND GROW.CONTINUE AND GROW.

OUR EXPERIENCEOUR EXPERIENCE

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IN SUCH MATTERS, TOP DOWN IS BAD; IN SUCH MATTERS, TOP DOWN IS BAD; BOTTOM UP ORGANIC GROWTH IS BOTTOM UP ORGANIC GROWTH IS GOOD.GOOD.

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VOLUNTARY IS BETTER THAN VOLUNTARY IS BETTER THAN INVOLUNTARY WHEN WILLING INVOLUNTARY WHEN WILLING COOPERATION IS NEEDED. COOPERATION IS NEEDED.

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INTEGRATION TAKES YEARS TO GROW; INTEGRATION TAKES YEARS TO GROW; DONDON’’T BELIEVE IN QUICK FIXES. T BELIEVE IN QUICK FIXES.

STILL MORE EXPERIENCESTILL MORE EXPERIENCE

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IT IS ARGUABLE THAT, IN TRYING IT IS ARGUABLE THAT, IN TRYING TO HELP HMOs BY PASSING THE TO HELP HMOs BY PASSING THE HMO ACT OF 1973, THE CONGRESS HMO ACT OF 1973, THE CONGRESS DID MORE HARM THAN GOOD.DID MORE HARM THAN GOOD.

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MUCH OF WHAT CONGRESS TRIES MUCH OF WHAT CONGRESS TRIES TO DO NOW IS TO UNDO THE TO DO NOW IS TO UNDO THE DAMAGE CAUSED BY PREVIOUS DAMAGE CAUSED BY PREVIOUS LEGISLATION.LEGISLATION.

SIZE IN A CONTIGUOUS SIZE IN A CONTIGUOUS AREA HELPS:AREA HELPS:

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TO OWN OR NEGOTIATE WITH TO OWN OR NEGOTIATE WITH HOSPITALSHOSPITALS

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TO TO ““INTERNALIZE SPECIALTIESINTERNALIZE SPECIALTIES””••

TO SPREAD OVERHEADTO SPREAD OVERHEAD

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150,000 PEOPLE IS TOO SMALL150,000 PEOPLE IS TOO SMALL••

500,000 PEOPLE IS A GOOD SIZE500,000 PEOPLE IS A GOOD SIZE

ON COMPETITION AND ON COMPETITION AND INTEGRATED CAREINTEGRATED CARE

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KP LEADERS RECOGNIZE THEY ARE A KP LEADERS RECOGNIZE THEY ARE A COMPETITORCOMPETITOR

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THEY KNOW THEIR MONEY COMES THEY KNOW THEIR MONEY COMES FROM SATISFIED MEMBERS WHO HAVE FROM SATISFIED MEMBERS WHO HAVE A CHOICEA CHOICE

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ROBUST COMPETITION DRIVES ROBUST COMPETITION DRIVES INNOVATION, AS IN I.T. ADOPTIONINNOVATION, AS IN I.T. ADOPTION

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SERVICE IMPROVEMENTS WERE DRIVEN SERVICE IMPROVEMENTS WERE DRIVEN BY COMPETITIONBY COMPETITION

ON PUBLIC REPORTINGON PUBLIC REPORTING……

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MOST PATIENTS DO NOT READ MOST PATIENTS DO NOT READ HEDIS REPORTS; PEOPLE ASK HEDIS REPORTS; PEOPLE ASK FRIENDS.FRIENDS.

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MEDICAL GROUP LEADERS DO MEDICAL GROUP LEADERS DO READ QUALITY REPORTSREAD QUALITY REPORTS

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CABG REPORTING IN NEW YORKCABG REPORTING IN NEW YORK••

PUBLIC REPORTING OF QUALITY PUBLIC REPORTING OF QUALITY DOES MOTIVATE IMPROVEMENTDOES MOTIVATE IMPROVEMENT

ON INTERNAL MECHANISMSON INTERNAL MECHANISMS

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PERMANENTE PAYS DOCTORS BONUSES PERMANENTE PAYS DOCTORS BONUSES FOR PATIENT SATISFACTION AND FOR PATIENT SATISFACTION AND TEAMWORK: MARKET DRIVENTEAMWORK: MARKET DRIVEN

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PERMANENTE PAYS BONUSES FOR PERMANENTE PAYS BONUSES FOR QUALITY: PUBLIC REPORTING DRIVEN, QUALITY: PUBLIC REPORTING DRIVEN, BUT THEY LED IN PUBLIC REPORTING IN BUT THEY LED IN PUBLIC REPORTING IN CONFIDENCE THEY WOULD LOOK CONFIDENCE THEY WOULD LOOK GOOD. GOOD.