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 Care
70
60
50 Patient Reported
(missing/duplicate tests)
40 2007
Doctor Reported (Often
30
or Sometimes) 2006
20
10
0
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 Integration
Burns 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
approaches
Needed to respond to local needs and circumstances
MSGP/Delivery System MSGP/Delivery System
with Payer without Payer
Network of Private Government Facilitated
Providers 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 system
Reputational marketplace Internal and External Influences
‐ National and Business Marketplace
international market
‐ For ideas, innovations ‐ Local/regional market
and reputation ‐ For patients/members
‐ In competition with the ‐ In competition with
“best – integrated delivery other plans and providers
and 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 .92
Pope 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 to
balance 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 risk
Monitor 2008

17. Lesson 3. Integrated Health
Information Technology is
essential in enabling the
integration 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
access
KP 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 systems
Commonwealth 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