2. HALLMARKS OF
INTEGRATED SYSTEMS I
• SHARED VALUES & GOALS
• ALIGNMENT OF INCENTIVES;
COMMON REVENUE STREAM
• PHYSICIAN LEADERSHIP
• A MANAGEMENT STRUCTURE
3. HALLMARKS OF
INTEGRATED SYSTEMS II
• COMPREHENSIVE RECORDS
• SHARED PRACTICE GUIDELINES
• ALL OR MOST OF A PATIENT’S
CARE WITHIN A SYSTEM
• PATIENT CENTERED
• CULTURE OF TEAMWORK
4. HALLMARKS OF
INTEGRATED SYSTEMS III
• INTEGRATION ACROSS SETTINGS
• POPULATION MEDICINE
• PERSONAL AND PUBLIC HEALTH:
EMPHASIZE HEALTH PROMOTION
& DISEASE PREVENTION
• SOMATIC AND MENTAL HEALTH
5. BENEFITS OF INTEGRATED
SYSTEMS
• HEALTH PROMOTION, DISEASE
PREVENTION
• EFFICIENT RESOURCE USE
• BETTER OUTCOMES?
6. 30-Day Mortality After Acute Heart Attack
KP NCal hospitals vs. all other hospitals in counties with KP hospitals
25
= statistically sig. p<0.01
20
KP THE REST
15
13%
10
8%
5
0
Source: OSHPD
7. BENEFITS OF INTEGRATION
• ACCOUNTABILITY; LEADERSHIP IN
PUBLICLY REPORTED QUALITY
MEASURES
• CONVENIENCE AS IN “ONE STOP
SHOPPING” AND “SAME DAY” OPEN
ACCESS. PATIENTS FEEL THE
“SYSTEMNESS”
• LEADING IN APPLICATION OF
INFORMATION TECHNOLOGY FOR EHR,
PATIENTS’ CONVENIENCE AND
CAREGIVER SUPPORT TOOLS
8. INTEGRATION IS A MATTER
OF DEGREE
• EVEN THE MOST INTEGRATED (KP
IN CA) REFER SOME CARE TO
SPECIALIZED REGIONAL CENTERS
• SOME INTEGRATE CARE BUT NOT
FINANCES
9. Integrated Care: how many
patients in the USA?
Common Revenue Streams
Kaiser Permanente 8.7million
Veterans Administration 5.7
Other PGP 4.5
Multiple Revenue Streams
Intermountain Healthcare 1.0
“California Delegated HMOs 9.0
Other Large MSGP 10.0
10. “California Delegated HMOs”
• Medical Groups paid per capita for
professional services by insurance
companies.
• Have poor incentives alignment.
Hospitals, Medical Groups, and
Insurance Companies have conflicting
objectives and interests.
11. WHY DON’T WE HAVE MORE
INTEGRATED SYSTEMS IN THE USA?
• ORGANIZED MEDICINE IN THE USA
CONDUCTED A BITTER WAR AGAINST
THEM UNTIL RECENT YEARS.
• MOST EMPLOYERS DO NOT OFFER THEM
AS COST CONSCIOUS CHOICES
• OFFERING CHOICES DOESN’T FIT MANY
EMPLOYERS
• INSURANCE COMPANIES RESIST
CONSUMER CHOICE OF PLAN
12. THE TRADITIONAL
FRAGMENTED SYSTEM
• “FREE CHOICE” OF DOCTOR
• “FREE CHOICE” OF TREATMENT
• FEE-FOR-SERVICE PAYMENT
• DOCTOR-PATIENT NEGOTIATION
OF FEES
• SOLO OR SMALL SS GROUP
PRACTICE
• PHYSICIAN AUTONOMY CULTURE
13. HOW COULD AMERICA GET MORE
INTEGRATED CARE?
• “OPEN THE MARKETS AND LEVEL THE
PLAYING FIELD”
• UNIVERSAL COVERAGE BASED ON
PRINCIPLES OF MANAGED
COMPETITION
• THE DUTCH HEALTH INSURANCE
MARKET COMBINED WITH AMERICAN
INTEGRATED DELIVERY SYSTEMS
14. Elements of Managed Competition
• “EXCHANGE” OR MARKET ORGANIZER
• INFORMED, COST CONSCIOUS,
CONSUMER CHOICE
• INDIVIDUAL (NOT GROUP) CHOICE
• RISK EQUALIZATION
• GUARANTEED ISSUE, COMMUNITY
RATING
• LEVEL PLAYING FIELD
• PRICE ELASTIC DEMAND
15. HOW COULD THE NHS GET TO
INTEGRATED CARE?
• “…POLICY MAKERS NEED TO
RESIST THE TEMPTATION TO
PRESCRIBE A SINGLE APPROACH
AND TO FOCUS INSTEAD ON
ENCOURAGING THE
DEVELOPMENT OF INTEGRATED
CARE USING THE MEANS THAT
APPEAR MOST APPROPRIATE IN
DIFFERENT CONTEXTS.” C. HAM
16. MORE WISDOM FROM THE
MASTER…
• “ PRIMARILY [INTEGRATION] IS
ABOUT RELATIONSHIPS BETWEEN
PEOPLE. THESE RELATIONSHIPS
ARE NOT INFORMAL FRIENDSHIPS.
THEY HAVE TO BE WORKED ON
AND BUILT PROFESSIONALLY IF
CLINICAL INTEGRATION IS TO BE
MEANINGFUL AND SUSTAINED
THROUGH GOOD AND BAD TIMES.”
17. IDS IN NHS?
• ENCOURAGE EMERGENCE OF
INTEGRATED SYSTEMS, BASED ON
NETWORKS OF LIKE-MIINDED GPs
WORKING TOGETHER TO PROVIDE
AND COMMISSION CARE FOR THE
POPULATIONS THEY SERVE. USE
BUDGETS TO INCLUDE SECONDARY
CARE SPECIALISTS.
18. IDS IN NHS?
• TOTAL PURCHASING PILOTS WERE
A GOOD DEVELOPMENT, GROWING
ORGANICALLY OUT OF
INDIVIDUAL FUNDHOLDERS. TOO
BAD THEY WERE NOT ALLOWED TO
CONTINUE AND GROW.
19. OUR EXPERIENCE
• IN SUCH MATTERS, TOP DOWN IS BAD;
BOTTOM UP ORGANIC GROWTH IS
GOOD.
• VOLUNTARY IS BETTER THAN
INVOLUNTARY WHEN WILLING
COOPERATION IS NEEDED.
• INTEGRATION TAKES YEARS TO GROW;
DON’T BELIEVE IN QUICK FIXES.
20. STILL MORE EXPERIENCE
• IT IS ARGUABLE THAT, IN TRYING
TO HELP HMOs BY PASSING THE
HMO ACT OF 1973, THE CONGRESS
DID MORE HARM THAN GOOD.
• MUCH OF WHAT CONGRESS TRIES
TO DO NOW IS TO UNDO THE
DAMAGE CAUSED BY PREVIOUS
LEGISLATION.
21. SIZE IN A CONTIGUOUS
AREA HELPS:
• TO OWN OR NEGOTIATE WITH
HOSPITALS
• TO “INTERNALIZE SPECIALTIES”
• TO SPREAD OVERHEAD
• 150,000 PEOPLE IS TOO SMALL
• 500,000 PEOPLE IS A GOOD SIZE
22. ON COMPETITION AND
INTEGRATED CARE
• KP LEADERS RECOGNIZE THEY ARE A
COMPETITOR
• THEY KNOW THEIR MONEY COMES
FROM SATISFIED MEMBERS WHO HAVE
A CHOICE
• ROBUST COMPETITION DRIVES
INNOVATION, AS IN I.T. ADOPTION
• SERVICE IMPROVEMENTS WERE DRIVEN
BY COMPETITION
23. ON PUBLIC REPORTING…
• MOST PATIENTS DO NOT READ
HEDIS REPORTS; PEOPLE ASK
FRIENDS.
• MEDICAL GROUP LEADERS DO
READ QUALITY REPORTS
• CABG REPORTING IN NEW YORK
• PUBLIC REPORTING OF QUALITY
DOES MOTIVATE IMPROVEMENT
24. ON INTERNAL MECHANISMS
• PERMANENTE PAYS DOCTORS BONUSES
FOR PATIENT SATISFACTION AND
TEAMWORK: MARKET DRIVEN
• PERMANENTE PAYS BONUSES FOR
QUALITY: PUBLIC REPORTING DRIVEN,
BUT THEY LED IN PUBLIC REPORTING IN
CONFIDENCE THEY WOULD LOOK
GOOD.
