The document discusses healthcare reform in the United States with the goal of cutting costs by 50% while improving quality and access. It argues that no single entity currently "owns" the regional healthcare system due to the separation of hospitals, insurance companies, and economic development agencies. The document proposes a model of integrated accountable care organizations that coordinate care across the entire population of a region through tools like medical homes, population health programs, and shared health information technology. The goal is an integrated system that achieves the cost and quality targets of healthcare excellence by 2015.

1. 2nd Curve Healthcare –
Who Owns the Space?
Getting it right by design
for the US
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2. What’s “Getting it Right?”
• Cut healthcare cost 50%
• Better quality
• Greater access
• More globally competitive economics
• Growth in jobs & take-home pay
• Minimum: cut care pct as grow GDP
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3. Four Key Actions…
Think Systemically
Create & Build
Transfer
Maintain & Sustain
__________________________________
(They spell “Act smart now for
Reform 2015!”)
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4. Regional Ownership Challenge…
• Regional outcome variance violates oath
• Why is payment an insufficient incentive?
• ANS: Payment per se doesn’t organize systems
• And, why is regional healthcare an orphan?
• ANS: No one owns the three-legged stool…
– Wide-area population space
– Wide-area provider space
– Regional health-based economic space
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5. Here’s Why No One Owns…
• Hospitals are largest competitive providers,
but not wide-area focused and harmonized.
• MCOs are largest wide-area players, but are
having trouble using financial disincentives &
rationing to improve provider & patient team
outcomes (no incentive for non-FFS policy).
• Regional agencies and funding for economic
and workforce development are outside the
healthcare conversation.
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6. A Way Forward to Reform 2015…
• Patient-focused systemic actions will
determine winners (accelerate ACOs).
• (Even before asserting that better
wide-area population health enables
stronger regional economies.)
• Needed – A Seven-layer Cake…
Plus Public Metrics
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7. The First 4 Layers (Big Stuff)…
• Milstein—medical home (practice level)
• Keene—medical village (population level)
• Asheville—region-wide care system
coordination, coaching, and patient
navigation (successful 10-yr Rx prototype)
• Hannaford—employee risk assessments
and healthy behavior credits (hint: scale
up to “nudge” whole regional population)
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8. The Final 3 Layers (Nitti-Gritty)…
• VA VistA—global patient data (patient & practitioner
design, not billing & admin), interpretive tools, enable
& mobilize global practitioner team to [support-track-
assess] care across [knowledge-decisions-actions]
• Virtual Expertise Centers—patient-focused and
distance-delivered regional practitioner skills, data
assembly, and interpretation: responsive, mobilized,
integrated access linking [patient-team-knowledge]
• Virtual Public Health Sensing+Visits—proactively look
for population-wide patterns (distance-enabled risk
assessment) & remotely deliver first-level follow-up
(distance care) – seamless hand-off to hands-on care
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9. Metrics—We Get What We Measure
• Patient Flow...
Wait times to first and next service
• Patient Safety…
Entry/continuity, discharge, infection, errors
• Patient Ratings...
Care, courtesy, process, perceived results
• Service Quality...
Measured results & re-admission rates
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10. Metrics Part 2 – Context…
• Patient Cost… Jeff Goldsmith recommends
– Primary care: risk-adjusted capitation payments
– Emergency care & diagnostic physician visits: fee-
for-service (FFS) payments [editorial—but stop
allocating hospital overhead to Emergency Depts.]
– Specialty care episodes: bundled payments adjusted
for severity [and for regional cost of living]
• Also…
– Dial down tort law & tort-distorted care
– Update legal frame (Mark McCue, Relational Law)
– Don't Compete on Safety (hold in common)
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11. ACO Value – Regional Ownership…
• ACOs: not only hospitals, practitioners, payors.
• Add patients, employers, populations, wide-area
harmonization, economic & workforce agencies.
• Idea: Interpret ACO value map as follows…
– Accountable to patient and region
– Care to whole regional population
– Organization around patients not providers or payors;
across silos, region, prevention, wellness, chronic and
critical care to link disciplines, distance, data, and time
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12. What is Possible?
• Medical Home (25% primary + specialist care
& variance cost cuts from evidence based care)
• Asheville Model (15% chronic care cost cut)
• Hannaford Model (10% health-based cost cut)
• Medical Village (region-wide population care)
__________________________________
50% Reduction in total cost of care
Better quality & greater access
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13. Real Challenges & Stories…
Challenges (Camille) Stories (Michael) Quotes (Michael)
“People have reorganized, Baylor “40% reduction of
are operating well, and avoidable harm. Saved
have removed the kinks” $80 million.”
“Providers are willing to Intermountain Health “Get smart clinicians
make changes on their talking to each other
own and are working well and continue those
together” kinds of dialogues”
“Insurance companies Mayo “11 of 14 surgeons are
(and payors) are working profitable under
with you” Medicare
Reimbursement”
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14. US Excellence 2015…
System Integration & Care Coordination
for Patients, Families, Regions
PUSH Accountable Care Organizations (refined) PULL
Accountable to patient and region
Care to whole region & population
Employers— Organization around patients, across silos & Government—
•Private Sector region—prevention, wellness, chronic, critical •Medicaid
•Public Sector Medical Home: Milstein—practice level •Medicare
Medical Village : Keene—region level •State & Regional
Care Coord & Coaching: Asheville—10+ years Economic &
-------------------------- Workforce
Risk Assessments, Healthy Behavior Credits, Agencies
Effective/Efficient Provider Preference:
Hannaford—employer & region levels
3rd Dimension: IT info exchange—context-based information for knowledge & action
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15. Transition: 1st Curve to 2nd…
“Theoretical Ideal” (IHI)
6+ sigma 


4 sigma (Culture of Safety&
 (Craft-age Excellence)
 Culture) (Now)

(1910)
Performance Time    
- adapted from Ian Morrison, The Second Curve. Managing the Velocity of Change , 1996
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