Post on 14-Dec-2014
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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
Copyright © 2010 Kaiser Permanente 3
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
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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)
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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
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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
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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
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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
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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”
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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
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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
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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)
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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
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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
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Systematic approach
…and accountability across the continuum from prevention to management of acute and
chronic cardiovascular disease
Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
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Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
Investing in Primary Prevention
Delivering the benefits: modify lifestyle increase HTN control smoking cessation decrease LDL cholesterol levels
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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
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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
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Primary Prevention
Secondary 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
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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
Secondary Prevention
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Primary Prevention
Secondary Prevention
AcuteCare
Chronic Care
Acute Care Cardiac Disease
Delivering the benefits: 7 Joint Commission Core Measures
Provide revascularisation to appropriate patients
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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
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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
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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”