Richard Gleave: Across the pond
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Across the Pond: possible lessons from the US about delivering integrated care Richard Gleave Harkness/Health Foundation Fellow 2007-08
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Transcript of Richard Gleave: Across the pond
Across the Pond:possible lessons from the US
about delivering integrated care
Richard GleaveHarkness/Health Foundation
Fellow 2007-08
The Basics of Good Management and Leadership
UK and US concepts of integration
UK• The NHS “family” • Horizontal integration
– teams of professionals
• Health and Social Care
US• Absence of a system• Address
fragmentation – thus focused on physicians and their relationships
• Motivators for integration
The Paradox of Perceptions
0
10
20
30
40
50
60
70
AUS NZ NETH US UK GERM CAN
Patient Reported(missing/duplicate tests)2007Doctor Reported (Oftenor Sometimes) 2006
Commonwealth Fund Surveys on Co-ordination of Care
Integrated (Delivery) Systems
Health Plan
PhysiciansHospitals
Drivers for Integration
Clinical Integration
Economic Integration
Non Economic Integration
Burns and Muller (2008)
Lesson 1: Integrated GovernanceThe successful approaches
in the US are always built upon strong clinical leadership and
robust management processes
Lesson 1a): A diversity of approaches
Needed to respond to local needs and circumstances
MSGP/Delivery System with Payer
MSGP/Delivery System without Payer
Network of Private Providers
Government Facilitated Network
Shih et al, Commonwealth Fund 2008
Kaiser Permanente Governance Structure
• Social purpose• Quality-driven• Shared accountability for
program success• Integration along multiple
dimensions• Prevention and care
management focus
KaiserFoundationHospitals
PermanenteMedicalGroup
KaiserFoundationHealth Plan
Health PlanMembers
Kaiser Permanente 2007
Business Marketplace
‐ Local/regional market‐ For patients/members‐ In competition with other plans and providers
Reputational marketplace
‐ National and international market‐ For ideas, innovations and reputation‐ In competition with the “best – integrated delivery and payer systems
Dominant Culture ‐Excellence – accountability and innovation‐Integration – plan andpatient care‐ Population Health alongside health care delivery‐Partnership of managers and physicians
Internal and External Influences
Lesson 1b): Culture supports structure in a system
Lesson 1c): Clear accountability needed in networks
New Organisation• Infrastructure Vendor• Value Based
Purchasing Coalitions
Designated Leader• The Integrator (IHI)
- system, - organizational and - patient level
Lesson 2: Risk and IncentivesBalance between
- aligning incentives to minimise risk (vertical integration in payer systems)
and- sharing/transferring risk (virtual integration in network models)
Lesson 2a): Risk Adjustment Methodologies
DxCG®, Inc.
Pope et al 2004)
Risk Categories Relative Risk Score
62 year old male .45
HCCs Diabetes with renal manifestations 5.71Type 1 diabetes .95Congestive heart failure 1.84Unstable angina .92Vascular disease with complication 1.20Vascular disease 0 (h)Dialysis status 18.09Diabetes with congestive heart failure .46 29.62
Lesson 2b): Payment systems need to balance vertical and virtual integration
Fee forService(FFS)
Episodeof Care
Payment(ECP)
Multi-ProviderBundledEpisodeof Care
Payment
Condition-Specific
Capitation
FullCapitation
CONTINUUM OF HEALTHCARE PAYMENT METHODS
PerDiem
Risk: Patient Overtreatment Risk: Patient Undertreatment
Miller 2008
Lesson 2c): Alignment between Payment Mechanisms
Lesson 2d): Internal management control to minimize provider risk
Monitor 2008
Lesson 3. Integrated Health Information Technology is
essential in enabling the integration of care, integration of
services and integration of structures.
Lesson 3a): Alternatives to large IT systems
Lesson 3b): IT focus on co-ordination of patient care
Lesson 3c): Member/Patient access
www.kp.orgMember Web Portal Make/change appointments
Send email to doctor
Check lab results
Access health Information
KP MyHealthConnect
Access medical record
Account summary
Care Delivery Core
Outpatient Inpatient
Scope of KP HealthConnect Suite
Scheduling
Registration
Clinicals
Billing
Scheduling
Admission, DischargeAnd Transfer
Clinicals
Billing
Pharmacy
EmergencyDepartment
Operating RoomReview eligibility & benefits
Differentiating Service Commodity Service
Lesson 3d): Support management information systems
Commonwealth Fund
Managed Care and Integrated Delivery
Health InsuranceVehicles
• Indemnity Insurance• Managed Care
– Health Maintenance Organization
• Delivery System HMO• Carrier HMO
– Preferred Provider Organization
– Hybrid
Health Care DeliveryVehicles
• Physician Organisation– Solo Practice– Independent Practice
Association– Group Practice
• System Organisation– Integrated Payer System– Physician Hospital
Organisation
