Why Harkness?• Had been on 3 study trips to see US healthcare: – 2001 ODP network (with Pam and Steve Pashley) – 2003/4 DH fact finding Kaiser and Evercare (with Steve Dunn) – 2007 Northern Ireland to Kaiser (with Tim Kelsey)These experiences left me very positivelypredisposed to further ‘study’ in the US!
Journey• Was working in Trafford with set of physician and management colleagues to develop ‘first principles’ model for integrated care and became involved with Nuffield policy work• Fellowship based at Stanford with Alan Garber• Now working as Senior Adviser on Health Reform for Republic of Ireland• Cannot be recommended highly enough - deserves it’s ‘life changing’ epithet
Highlights • You mean I get to meet these people: Karen Davis, Mayor Bloomberg, Alan Garber, Don Berwick, Brent James, Elliot Fisher, Larry Casalino, Alain Enthoven, George Clooney, Julian Legrande, Karen Davis, Ken Kizer, Don Light, Jay Crossen, Karl Ulrich – extraordinary fellow fellows!Being published…Light, D and Connor, M ‘Reflections on commissioning and the English coalitiongovernment NHS reforms’ Social Science & Medicine, 2011, vol. 72, issue 6, pages821-822Connor, M ‘Local innovation can’t be driven from the top down’ British MedicalJournal, 2011;343:d5719 doi: 10.1136/bmj.d5719Integrated Delivery Systems and lessons for health reform in England (prepped forsubmission)
There is much more talk about systems (andintegration) than clarity about what we mean…
MethodologyResearch question: Can we be more explicit about step 2?Systems selected following key informant interviews and literature review:Marshfield Clinic, Veteran’s Health Administration, Kaiser Permanente,Intermountain HealthcareAll established and mature integrated delivery systems, albeit with verydifferent ‘natural histories’Semi-structured interviews, publically available and private literature, sitevisitsWork involved c. 37 interviews undertaken at four site visits and meetingswith system leaders
Map of Marshfield Clinic service area (Wisconsin)
Natural historiesMarshfieldOriginal group started in 1916 with 6 physiciansGrew organically until the mid-70s when it underwent a rapid expansion through acquiringan extensive network of community based primary care and small group practices (a ‘turn’to primary care)Very long-standing commitment to EHR with some health records going back to the 1970sand a genetic engineering research facility with 20,000 patients registered with geneticinformation, blood samples and electronic histories (can trace Germanic family lines…)The clinic is nationally recognised for its ICT and managed to convert its entire clinicalsystem into a paperless operation in three years from 2004 – 2007 and every physician nowpractices on a laptop – as I directly observedAchieved by far the highest level of savings (>$30m) of any of the 10 PGP demo sites from2005 – 2010, which it is now investing in getting NCQA accreditation for all its primary caresites as medical homes
Natural historiesThe VHAEstablished after WWI to provide care for veterans suffering as a result of their militaryservice (though some accounts trace its roots to the first federal military veterans hospitalin Pittsburgh in 1778)Its beneficiaries expanded massively after WWII, Korea and Vietnam and a series of high-profile quality problems led to a major loss of confidence in the 1980s and 1990sUnderwent a major re-engineering and transformational change from 1995 – 1999 underthe leadership of Ken Kizer (not least based on universal primary care)RAND study (04) found VHA outperformed the rest of US healthcare on 294 measures ofquality… CBO (09) said care ‘compared favourably’ with that given by non-VHA providersEspecially noted for its extraordinary VistA open-source EMR and very strong relationshipswith academic centres for research and physician training
Natural historiesKaiser PermanenteFounded in 1942 by Henry Kaiser and Sidney Garfield from a history of industrial healthmanagement associated with the Colorado River Aquaduct, the Grand Coulee Dam andWWII shipbuilding.From its inception was closely associated with a primary care model – developed to offerefficient care for workers and their familiesLost $770m in failed attempt to write its own IT system with IBM, which led to a newapproach, ultimately with Epic Systems, to implement HealthConnect – ‘the largest civilianelectronic medical record system’, implemented at a cost of $6bn, or c $500k per physicianIt has a tri-partite structure of KP Hospitals, the Permanente Medical Group(s) and the KPhealth plan, seen as ‘three legs of a stool’ and fully aligned strategicallyScores highly in State and national quality reports – in 2009 becoming the first HMO to get4 out of 4 stars in the ‘Meeting National Standards of Care’ category
Map of Intermountain Healthcare facility locations
Natural historiesIntermountain HealthcareInitially formed as the entity for the LDS to spin out its hospitals in the mid-70sExperienced significant ‘mission conflict’ (Brent James’ term) in implementing cost controlstrategies in the 80s and a failed venture into the insurance marketFormed its medical group only in 1995 and its differentiation into a systematically managed,high-quality system dates from this time – 75% primary care at inceptionLike Marshfield, has a long history of EHR going back to the 70s and is presently engaged ina massive renewal of its system, partnering with GE, into which it is incorporatingstandardised workflow associated with agreed models of careOnly system to be ranked No 1 out of 600 5 times in the Modern Healthcare/ Verispanannual rankings (in 2000, 03, 04 and 05… it came second in 01, 06 and 07) (wonder whathappened in 2002)Has developed and runs the world-class Advanced Training Programme for clinicians inquality improvement
5 ‘structural similarities’ of the IDSs studies1) Mapping of population to primary care physician2) Systematic accountability for PCPs as providers in the context of integrated system3) Shared governance (PCPs and specialists in the same business)4) Multi-specialty physician group controls/shapes hospital services/ contract using make or buy5) Physician-led commitment to information systems
Can we discern a ‘strong archetype’? Overall physician control No ‘skin in the game’ for GPs GP or consultants registered thus left to list GPs only formally management accountable for cadre primary care piece Specialist teams Hospital services Primary CarePopulation Shared Virtual or Mapped to governance actual with control of Commissioning, compettion and choice make MSMGP difficult or impossible Domain defined by Strategic Heath Information Teams EHR (Electronic)
CONCLUSIONFirst, by establishing Clinical Commissioning Groups in the same evolutionaryline as PCGs and PCTs, the reforms persist in placing GP leaders on one side as‘purchasers’ with the hospitals on the other side as ‘providers’. Thisoppositional structure is likely to end up in the same space as its predecessors –with weak control and little in the way of integrated working.Second, the particular emphasis on ‘Any willing provider’ and ‘patient choice’means that it is difficult to conceive how GPs and consultants could formanything like the multi-specialty physician group entity that lies at the heart ofthe successful integrated systems in the US without falling foul of the regulatoryregime. This makes it impossible for the right locus of integration to bedeveloped that can truly consider the cost-benefits of ‘make or buy’ decisions.Since both the development of CCGs and the commitments to competition andpatient choice in these particular ways remain cornerstones of the coalitionplans, it is doubtful that they will produce anything like clinical integration thathas been successful in the US.