Sharon Levine on integrated care - the role of multispeciality medical practice in promoting...

A 60 Year Journey, With No End in Sight

Sharon Levine, M.D.Associate Executive DirectorThe Permanente Medical Group

March 31 2011Copyright © 2011

Kaiser Permanente

Multispecialty Group Practice

Leveraging Integration, Partnership and Physician Responsibility to

Deliver Performance

Copyright © 2010 Kaiser Permanente 2

Kaiser Permanente (KP)

Integrated delivery system (hospitals and clinicians) and financing scheme – equal partners, separate entities

Origin as provider “cooperative”

Operates like a mini “national health system” Single funding stream

Global budget

Accountable for total health of a population

Unlike much of US healthcare

Compete in the market for sponsors (employers), members, physicians, employees, based on:

Quality

Efficiency/value

Member/patient satisfaction

Quality of professional life


Our model

Social purpose Quality-driven Shared accountability for

program success Integration along multiple

dimensions Prevention and care

management focus

Kaiser Foundation Hospitals

PermanenteMedicalGroups

KaiserFoundationHealth Plan

Health PlanMembers

Kaiser Permanente: an integrated model of health care financing and delivery, a unique relationship among three separate entities – partnership, contract, and exclusive


Kaiser Foundation Health Plan

POPULATION

Kaiser Foundation Hospitals

Permanente Medical Group

Health Plan Members

Medical Service Agreement

Hospital Service Agreement

Group/Individual Contracts: multi-payer, single revenue stream to delivery system

Operating Budgets Capitation to the Group

REVENUE

EXPENSE---------------------------------------------------------------------------------------------------------------------

KP Operating Model – (1955)


Multispecialty group practice: from the beginning primary care and specialty care co-located partners

Collaboration rather than competition Efficient, effective management of complex, chronic illness Peer review, quality oversight – examined practice

Flow of funds: pre-payment to the Health Plan, capitation to the Medical Group, hospital as cost center

Aligned incentives, investment mind-set, salary in lieu of fee-for-service

Kaiser Permanente Model of Care DeliveryFour Foundational Innovations

Reverse economics: health promotion, disease prevention Mutually exclusive partnership of equals between

Kaiser Foundation Health Plan and a self-governed, self-managed Permanente Medical Group – joint decision making & governance

Essential in competing for physician talent – then and now Requires the skills, competencies and knowledge to lead and co-manage


The Partnership

Kaiser Foundation

Health Plan, Inc..

Regional Permanente

Medical Groups

Regional Health Plans

The Permanente

Federation, LLC

Articles of Federation

National Partnership Agreement

Medical Service

Agreements/MOUs

Partnership Within the Region

Health Plan/Hospital Leader

• Common Vision• Exclusivity• Joint Governance and Decision-Making• Aligned incentives

Physician-in-Chief


Integration: “Secret Sauce”

“To make whole or complete by bringing together the parts”, but …

To be successful “the whole” must deliver substantially more value to payors, beneficiaries, physicians, and employees than the “sum of the parts”

The right care to the right patient at the right time in the most appropriate setting – safe, effective, efficient error free

Shared commitment to eliminating functional, structural, budgetary impediments to efficiency – ongoing effort: behave in a trustworthy manner

Rational budget practices: $’s follow the patient

Aligned incentives across and within entities


Integration of care and service

Integration in care delivery: Primary care, specialty care – equal partners; ancillary

providers, and ancillary diagnostic and therapeutic services co-located, part of care teams

“Continuum of care” – home, provider office, hospital, nursing home/SNF; role of telehealth

Continuum of an illness – primary and secondary prevention, diagnosis, treatment, chronic care management and follow-up, supportive care, and palliative care – from “potential” to “real”

Integration “over time” – long time horizon, investment mindset


Integration: Primary and Specialty care

Why so important? Seamless care – clarity among clinicians about who is

responsible for what

Ongoing, and constant, collaboration and negotiation about accountabilities, cross-cutting QI activities

Care co-ordination for patients with chronic conditions, patients with complex care needs

Capacity to address gaps, handoffs – every one owns it

Aligned incentives, “shared fate”

“Make, when you can, buy when you must”


Culture: Shared accountability for the Enterprise

Physician responsibility for quality and cost of care – somewhat unique in US healthcare until very recently

Peer accountability: common medical record and “examined practice” for quality and efficiency in care delivery – even before we had an EMR

Shared and individual accountability – stewardship for member resources and for the health of populations collectively, in addition to duty to individual patients

Broad engagement in “shared accountability” efforts enables “individual autonomy” in the examination room and at the bedside.

Salaried physicians, with strong (personal) incentives re quality, neutral re volume/quantity of services provided


Clinician accountability

Accountability exercised through self-managed and self-governed medical groups

Responsibility for clinical care and patient satisfaction, quality improvement, resource management, design and operations of care delivery system

Physician leaders emerge from clinical ranks, then trained in business knowledge, leadership, and management skills: professionals leading professionals

Broad, distributed model for leadership –

Intentional effort to recruit for leadership – “every physician a leader”

Substantial investment in customized management training and leadership development

Leader’s role – build and maintain a culture of pride, performance and accountability


Performance

Ultimately, structure and governance are important as “facilitators”; but only if they deliver value, and facilitate continued performance improvement

This requires… effective and committed leadership aligned incentives culture of performance and accountability

It’s about results…

“The American health care system is more expensive than any other, without providing better results. The cure (says Brent James) is measurement.” (New York Times Magazine, 11/08/09)


Data that drives performance

The “cure”… advanced clinical and management information systems

“Revealing reports” – gap identification

“Data that drives” performance improvement – clear, actionable, timely

A delivery system willing to, and capable of, using the data for rapid cycle improvement team-based, clinician-led process redesign


Translating evidence into benefit: Cardiovascular disease

Evidence Benefits

Abundant body of evidence A 13 point reduction in blood pressure can lower

deaths due to CVD by 25% 4 generic medications can reduce CV event risk by 50%. 7 interventions in the ED/Hospital can reduce mortality Managing transition of HF patients from hospital to home

can reduce readmissions and prevent catastrophic declines


Systematic approach

…and accountability across the continuum from prevention to management of acute and

chronic cardiovascular disease

Primary Prevention

Secondary Prevention

AcuteCare

Chronic Care


Primary Prevention


AcuteCare

Chronic Care

Investing in Primary Prevention

Delivering the benefits: modify lifestyle increase HTN control smoking cessation decrease LDL cholesterol levels


Action Description Outcome

CheckWas BP taken and recorded? Documentation

Was BP high? The denominator

Treat Was treatment intensified ?Upward titration of dose and/or medication type

Repeat

Was there another BP taken within 4 weeks?

Follow up care

Was the f/u BP lower than the initial BP?

Better Control of BP

Was the f/u BP in control? Controlling BP

Increase Hypertension ControlPrimary Prevention

Dissecting the process, making the process clearer and easier…enables action


Adult Smoking Prevalence 2002 and 2005

23.0%

16.4%

12.2%

20.9%

15.2%

9.2%

0%

5%

10%

15%

20%

25%

United States California Kaiser PermanenteNorthern California

Healthy People 2010 Target

Survey Population

% A

dult

popu

latio

n wh

o cu

rren

tly s

mok

e 10%

7.5%

25%

Spectrum of Cardiac Care

Primary PreventionNCAL Leads in Smoking Cessation

Adult Smoking Prevalence 2002 vs. 2005

USA Calif. KP(NCAL)

12%

2010 Target


Primary Prevention


AcuteCare

Chronic Care

Crossing the Chasm Secondary Prevention

Delivering the benefits: PHASE population Heart protective meds: Aspirin, Statin, ACE-I, and Beta-blocker

Lifestyle changes: Tobacco cessation, physical activity, healthy eating and weight management

Risk factor control: blood pressure, cholesterol and blood sugar


Impact of 2007/08 improvements

Additional 13,900 patients at LDL target430 heart attacks/strokes prevented

Additional 3,000 patients on statins220 heart attacks/strokes prevented

Additional 2,200 patients on ACEI 90 heart attacks/strokes prevented

Additional 7,250 people with Diabetes at A1c <9350 adverse outcomes prevented

Additional 17,495 people with Diabetes have BP < 129/ 791452 CV events prevented



Primary Prevention


AcuteCare

Chronic Care

Acute Care Cardiac Disease

Delivering the benefits: 7 Joint Commission Core Measures

Provide revascularisation to appropriate patients


ST Elevated MIs are declining

ST Elevated MI

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Ag

e/S

ex A

dju

sted

Rat

e p

er

1000

ST Elevated MI

ST Elevated Myocardial Infarction - Age/Sex Adjusted Hospitalization Rates for Kaiser Permanente, 1998 - 2007


Improving outcomes

YearTotal AMI

Admissions Total AMI

Hospital Deaths % Mortality

2005 6,406 390 6.1%

2006 5,947 356 6.0%

2007 5,576 279 5.0%

2008 5,473 256 4.7%

2009 5,156 188 3.6%52% reduction in AMI hospital deaths since 2005


Performance Improvement Levers What’s changed?

Multispecialty group practice

Physician leadership – committed and competent

Aligned incentives

Credible clinical champions

Data that drives improvement – timely, actionable, information technology

Capacity for change and speed of improvement

Patient engagement and activation

Project management

Reward/recognition/celebration of success – “Pride4P”

Sharon Levine on integrated care - the role of multispeciality medical practice in promoting...

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Transcript of Sharon Levine on integrated care - the role of multispeciality medical practice in promoting...