A Health Care System...
(Everyone
and every
thing else)
Patient
Creating a Health Care System
National Health Policy Conference
Washington DC
February 2, 2009
Paul Wallace MD
The Permanente Federation
Kaiser Permanente
Paul.Wallace@kp.org
Payor
Prepayment
(Global Capitation)
PCP
Payment evolution...
Physician
Leadership
Manage Budgets,
not Revenue
Accountability for
both Primary and
Specialty Care
Mutual Exclusivity
Between Payor
And Providers
Capital
Management
•“Bricks”
•“Clicks”
HIT
2
Kaiser Permanente – An Integrated Delivery System
Not for profit
Health Plan
Specialist
Move from exclusively
managing revenue
towards managing a
budget
Multi-Specialty
Medical Groups
Progress to anything
but pure Fee For
Service...
Research and
Innovation
Infrastructure
Investment
Knowledge
Generation
Labor-Mgmt
Partnership
Population Care...
1 Patient at a time
3
Source: T Lee and R. Berenson, The Health Care
Delivery System: A Blueprint for Reform, 2008,
The Center for American Progress and
The Institute on Medicine as a Profession
4
Infrastructure: Primary Care Physicians and How They
“Manage” Their Patient Panel
Accountability:
Medical homes and Neighborhoods
Before Panel Management
Customizing the
Medical Home for
Population Care:
¾HIT
¾Decision support
¾Predictive modeling
¾Practice models
# of "Contacts" per doc per day
40
The Medical Neighborhood
¾Scale economies
¾Shared services
¾Integrated Primary and
Specialty Care
35
Phone contacts
30
25
20
15
10
Office visits
5
0
1
5
6
1
Diversified Access: Time and “Touches”
Average Daily "Touches"
80
US mail contacts
No. of Daily Contacts
70
RN and HCT contacts
60
Email contacts
50
Phone contacts
40
Annual health goals
30
"Fast Track"'s
20
Group visits
10
0
7
Email contacts
Phone contacts
300
Annual health goals
200
"Fast Track"'s
Group visits
100
Office visits
0
Email contacts
50
Check lab results
Access health Information
Annual health goals
30
Clinicals
Review eligibility & benefits
"Fast Track"'s
20
Group visits
10
Billing
Account summary
Office visits
1
9
Knowledge Generation: Managing the “Gray Areas”...
?
The last 115 new technologies examined:
7
Insufficient evidence
because the
evidence is:
10
Knowledge Generation: Managing the “Gray Areas”...
The last 115 new technologies examined:
38
Scheduling
Registration
Phone contacts
40
Dr G. Livaudais, Maui Lani Clinic, Hawaii,
“Gerard.F.Livaudais @KP.ORG”
Medically
appropriate
Care Delivery Core
Make/change appointments
Send email to doctor
RN and HCT contacts
60
0
1
Access medical record
US mail contacts
70
US mail contacts
No. of Daily Contacts
Minutes
www.kp.org
Member Web Portal
80
RN-HCT contacts
8
Expanded Online Access for Members
Average Daily "Touches"
500
400
Dr G. Livaudais, Maui Lani Clinic, Hawaii,
“Gerard.F.Livaudais @KP.ORG”
Infrastructure:
Members Can Actively Participate in Care
Diversified Access: Time and “Touches”
Physician Time
Use When Care is
More Diversified
Office visits
1
Generally not
medically
appropriate
Medically
appropriate
7
38
Insufficient evidence
because the
evidence is:
A. Of insufficient
quantity
66
and/or quality
A. Of insufficient
quantity
66
and/or quality
B. Conflicting or
inconsistent 3
B. Conflicting or
inconsistent 3
C. There is no
evidence
1
C. There is no
evidence
1
11
11
Generally not
medically
appropriate
12
12
2
Moving towards an Integrated Delivery System:
Key investments of $$$ and effort
Comparative Population Effectiveness: The Kaiser
Permanente National Joint Replacement Registry
[Evaluation]
feedback
changed practice
with respect to:
implant selection,
minimally
invasive
procedures,
uncemented
knees, and
surgical
indications and
preoperative care.
Paxton,EW et al; The
Permanente Journal
15:12-16, 2008
13
Is there critical mass of change to collectively create
a new Health Care System?
Shift to a focus on managing budgets, not revenue:
¾ Evolve beyond 100% FFS
Care management fees
Episode pricing
Shared accountability for both primary and specialty care:
¾ Build Medical Neighborhoods
Population management
Referral management
Infrastructure Investment:
¾ HIT – move beyond the EMR
Registries/Health Information Exchange
Personal Health Records
Knowledge Generation:
¾ Rapid Learning/“Managing the Gray Areas”
Comparative population effectiveness
Care models
14
The Patient at the Center of Care
Payment Evolution from FFS
HIT for Population and Personal Care
Patient
Medical Neighborhoods
Payor
Specialist
HIT
(Everyone
and every
thing else)
PCP
Illustration by Tom Benthin, Copyright © Kaiser Permanente
15
16
3