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Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
Richard Gleave: Across the pond
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Richard Gleave: Across the pond

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  • 1. Across the Pond:possible lessons from the US about delivering integrated care Richard Gleave Harkness/Health Foundation Fellow 2007-08
  • 2. The Basics of Good Management and Leadership
  • 3. UK and US concepts of integration UK US• The NHS “family” • Absence of a system• Horizontal integration • Address – teams of fragmentation – thus professionals focused on physicians• Health and Social and their relationships Care • Motivators for integration
  • 4. The Paradox of Perceptions Commonwealth Fund Surveys on Co-ordination of Care706050 Patient Reported (missing/duplicate tests)40 2007 Doctor Reported (Often30 or Sometimes) 200620100 AUS NZ NETH US UK GERM CAN
  • 5. Integrated (Delivery) Systems Health Plan Hospitals Physicians
  • 6. Drivers for Integration Clinical Integration Economic Integration Non Economic IntegrationBurns and Muller (2008)
  • 7. Lesson 1: Integrated Governance The successful approaches in the US are always built upon strong clinical leadership and robust management processes
  • 8. Lesson 1a): A diversity of approachesNeeded to respond to local needs and circumstancesMSGP/Delivery System MSGP/Delivery Systemwith Payer without PayerNetwork of Private Government FacilitatedProviders Network Shih et al, Commonwealth Fund 2008
  • 9. Kaiser Permanente Governance Structure• Social purpose• Quality-driven• Shared accountability for Permanente program success Medical• Integration along multiple Group dimensions• Prevention and care management focus Health Plan Members Kaiser Kaiser Foundation Foundation Hospitals Health Plan Kaiser Permanente 2007
  • 10. Lesson 1b): Culture supports structure in a systemReputational marketplace Internal and External Influences‐ National and  Business Marketplaceinternational market‐ For ideas, innovations  ‐ Local/regional marketand reputation ‐ For patients/members‐ In competition with the  ‐ In competition with “best – integrated delivery  other plans and providersand payer systems Dominant Culture  ‐Excellence – accountability  and innovation ‐Integration – plan and patient care ‐ Population Health alongside  health care delivery ‐Partnership of managers  and physicians
  • 11. Lesson 1c): Clear accountability needed in networks New Organisation Designated Leader• Infrastructure Vendor • The Integrator (IHI)• Value Based - system, Purchasing Coalitions - organizational and - patient level
  • 12. Lesson 2: Risk and Incentives Balance between- aligning incentives to minimise risk(vertical integration in payer systems) and - sharing/transferring risk (virtual integration in network models)
  • 13. Lesson 2a): Risk Adjustment Methodologies Relative Risk Categories Risk Score 62 year old male .45 HCCs Diabetes with renal manifestations 5.71 Type 1 diabetes .95 Congestive heart failure 1.84 Unstable angina .92Pope et al 2004) Vascular disease with complication 1.20 Vascular disease 0 (h) Dialysis status 18.09 Diabetes with congestive heart failure .46 29.62 DxCG®, Inc.
  • 14. Lesson 2b): Payment systems need tobalance vertical and virtual integration CONTINUUM OF HEALTHCARE PAYMENT METHODS Risk: Patient Overtreatment Risk: Patient Undertreatment Fee for Per Episode Multi-Provider Condition- Full Service Diem of Care Bundled Specific Capitation (FFS) Payment Episode Capitation (ECP) of Care Payment Miller 2008
  • 15. Lesson 2c): Alignment between Payment Mechanisms
  • 16. Lesson 2d): Internal management control to minimize provider riskMonitor 2008
  • 17. Lesson 3. Integrated Health Information Technology is essential in enabling theintegration of care, integration of services and integration of structures.
  • 18. Lesson 3a): Alternatives to large IT systems
  • 19. Lesson 3b): IT focus on co- ordination of patient care
  • 20. Lesson 3c): Member/Patient accessKP MyHealthConnect Access medical record Care Delivery Core Scope of KP HealthConnect Suite www.kp.org Make/change appointments Outpatient Inpatient Member Web Portal Scheduling Scheduling Send email to doctor Admission, Discharge And Transfer Check lab results Registration Clinicals Pharmacy Access health Information Clinicals Emergency Department Review eligibility & benefits Operating Room Billing Billing Account summary Differentiating Service Commodity Service
  • 21. Lesson 3d): Support management information systemsCommonwealth Fund
  • 22. Managed Care and Integrated Delivery Health Insurance Health Care Delivery Vehicles Vehicles• Indemnity Insurance • Physician Organisation – Solo Practice• Managed Care – Independent Practice – Health Maintenance Association Organization – Group Practice • Delivery System HMO • System Organisation • Carrier HMO – Integrated Payer System – Preferred Provider – Physician Hospital Organization Organisation – Hybrid

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