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Jay Crosson on integrated care - lessons from the US

Jay Crosson, Senior Adviser for The Permanente Medical Group, shares his experience of integrated health care systems in the US and looks at incentives to support integration between primary and secondary care.

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Jay Crosson on integrated care - lessons from the US

  1. 1. Delivery system reform, ACOs and physician-hospital integration The King’s Fund London March 31 2011 Francis J. Crosson, MD The Permanente Medical Group Kaiser Permanente Institute for Health Policy The post-health care reform environment in the U.S.
  2. 2. Rationale for delivery system reform <ul><li>Control of escalating health care costs will be necessary for the sustainability of health care reform </li></ul><ul><li>How care is delivered has a major impact on health care costs </li></ul><ul><li>Changes to both the structure of and methods of payment to health care providers will be necessary to produce significant changes in health care delivery and the trajectory of health care costs </li></ul>
  3. 3. Delivery system – structural and payment change
  4. 4. Parallel tracks?
  5. 5. Accountable Care Organisations (ACOs) <ul><li>Definition </li></ul><ul><li>Origins and evolution of the concept </li></ul><ul><li>ACOs in health care reform legislation -The Affordable Care Act of 2010 (ACA) </li></ul><ul><li>Issues/barriers regarding ACO formation </li></ul>
  6. 6. ACOs – one definition <ul><li>“ The defining characteristic of an ACO is that a set of physicians and hospitals accept joint responsibility for the quality of care and the cost of care received by the ACO’s panel of patients” </li></ul><ul><li>MedPAC Report to the Congress, June, 2009 </li></ul>
  7. 7. The Council of Accountable Physician Practices (CAPP) <ul><li>Evolved in 2002 from discussions within American Medical Group Association </li></ul><ul><li>Sponsored and published research about multispecialty group practice </li></ul><ul><li>Sponsored colloquia and individual presentations about the role of multi-specialty group practice </li></ul>
  8. 8. <ul><li>Intermountain Health Care </li></ul><ul><li>The Jackson Clinic </li></ul><ul><li>Lahey Clinic </li></ul><ul><li>The Marshfield Clinic </li></ul><ul><li>Mayo Clinic </li></ul><ul><li>Mayo Health System </li></ul><ul><li>Nemours </li></ul><ul><li>Ochsner Clinic </li></ul><ul><li>Palo Alto Medical Foundation </li></ul><ul><li>The Permanente Federation (8 PMGs) </li></ul><ul><li>Scott & White </li></ul><ul><li>Sharp Rees-Stealy Medical Group </li></ul><ul><li>Virginia Mason Medical Center </li></ul><ul><li>Wenatchee Valley Medical Center </li></ul>CAPP groups <ul><li>Austin Regional Clinic </li></ul><ul><li>Billings Clinic </li></ul><ul><li>The Cleveland Clinic </li></ul><ul><li>Dean Health System </li></ul><ul><li>Duluth Clinic </li></ul><ul><li>The Everett Clinic </li></ul><ul><li>Fallon Clinic </li></ul><ul><li>Geisinger Clinic </li></ul><ul><li>Group Health Permanente </li></ul><ul><li>Harvard Vanguard Medical Associates </li></ul><ul><li>HealthCare Partners Medical Group </li></ul><ul><li>HealthPartners Medical Group </li></ul><ul><li>Henry Ford Medical Group </li></ul>
  9. 9. Dr. Elliott Fisher ACO papers <ul><li>“ Creating Accountable Care Organizations: The Extended Medical Staff”, Health Affairs, 2007,26:w44-w57 </li></ul><ul><li>“ Fostering Accountable Health Care; Moving Forward in Medicare, Health Affairs, 2009, 28:w219-w231 </li></ul><ul><li>“ Higher Health Care Quality and Better Savings Found at Large Multispecialty Medical Groups”, Health Affairs, 2010, 29:5 991-997 </li></ul>
  10. 10. ACOs in the ACA and beyond <ul><li>Medicare is asked to lead </li></ul><ul><li>ACA, Sec. 3022, Medicare Shared Savings Program </li></ul><ul><li>ACA, Sec. 3021, Medicare/Medicaid Innovation Center </li></ul><ul><li>Multiple private sector activities are underway as well </li></ul>
  11. 11. Key ACO design elements <ul><li>How is the population served established? </li></ul><ul><li>What payment/incentive designs are most likely to be successful in improving quality and mitigating unnecessary cost increases? </li></ul><ul><li>How to establish aligned incentives for physicians and hospitals? </li></ul><ul><li>Who will lead: physicians or hospitals? </li></ul>
  12. 12. Barriers to ACOs/Integration <ul><li>Knowledge and skills needed to be successful </li></ul><ul><li>Inadequacy of current payment incentives and up-front costs </li></ul>
  13. 13. ACA Shared Savings Model California “Delegated Model” Full Risk Capitation Corridor Capitation FFS +/- “Bonus” FFS + “Bonus” FFS Only Bundled Payments Medicare Group Practice Demo PCMH Primary Care Specialty Care Admin. Rx (B) Referral Costs Non Referral Costs Hospital Costs Prescription Rx (D) A Schematic of ACO Risk Assumption “ Breadth” of Risk “ Depth” of Risk Permanente Medical Groups
  14. 14. Barriers to ACOs/Integration <ul><li>Knowledge and skills needed to be successful </li></ul><ul><li>Inadequacy of current payment incentives and up-front costs </li></ul><ul><li>Anti-trust laws and other regulations </li></ul><ul><li>Private payer concerns about ACO market power </li></ul><ul><li>Physician/hospital cultural and governance issues </li></ul>
  15. 15. How did this book come about? <ul><li>Delivery system reform was on the horizon </li></ul><ul><li>There was a need to collect and organise the best thinking about how DSR might change the relationships between physicians and hospitals </li></ul><ul><li>Meanwhile hospitals were acquiring physicians </li></ul><ul><li>There was/is a need to show the central role of physician leadership in reformed health care delivery systems </li></ul>
  16. 16. Chapter 11: What needs to happen next?