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    Saturday, July 15, 2006

    Shape of Things to Come II: Is this the future of healthcare?

    One of the most hopeful things we discovered in the course of this research is that the revolution, if you will, has already started. The U.S. [healthcare] system can be reformed from the bottom up. Any hospital, physician practice, health plan, or employer can take positive steps in the direction of value-based competition today and be better off, even if nobody else changes. They will be more efficient, achieve better customer satisfaction, and the physicians involved will feel more pride in what they are doing. We included many examples in the book, such as the Cleveland Clinic, M. D. Anderson Cancer Center, and Dartmouth Hitchcock Medical Center, which are moving toward results measurement and integrated practice unit structures.

    "Integrated practice unit structures." What's that? Beats me, and Google. I like to think of my office as an "integrated practice unit," but I'm not sure that's what this guy has in mind. Heck, I think I myself, and every other primary care physician is an "integrated practice unit." We care for the "integrated patient unit," also known as the "whole person."

    It isn't clear from the discussion, but I get the impression that "integrated practice unit structures" mean hospital or corporate owned practices with multiple specialities within one corporate structure. This is also known as the multispecialty group, a concept that has been around since at least 1892. My experience with multi-specialty groups (and I have worked in that environment) is that each specialty spends a great deal of time and energy in the politics of protecting their own interests. Patient care and quality doesn't necessarily improve with an "integrated" structure. Sometimes, it suffers. Doctors in a group feel compelled to consult only those within their group, no matter how dismal their performance. And don't kid yourself if you think the group fires those who are barely adequate. It's very hard to fire or dismiss people unless they are downright dangerous. Fpr one thing, it's a legal nightmare. For another, it's human nature to want to avoid unpleasant conflict with colleagues. "Integrated practices" also have a tendnecy to urge more procedures on patients, since that's what the specialists among them do best and for which the reap the most rewards, rewards that are passed on to the group as a whole.

    But wait, maybe I'm wrong about that "integrated unit." What if it's the health insurance companies?

    Why do we need health plans? We need them to integrate across all of an individual's health needs. Some make the case that an integrated provider system can play the role of integrator. We reject that idea because it is crucial to have competition at provider and medical condition levels.

    So a value-based system keeps the health plan separate from the provider, and providers compete at the medical condition level. The health plan is also indispensable in aggregating information. We think the health plan is the logical place in the system at which to aggregate medical records. Right now, the medical record resides with providers, and one provider can request the record from another. That is a very cumbersome and inefficient system, which creates delay and duplication.

    Health plans should also inform and advise members about where to seek care, and help to navigate the care cycle. Many health plans, among them Harvard Pilgrim and Aetna, are starting to move in these directions. Health plans must become health organizations, rather than see themselves as payers or insurance companies.

    Don't you like that bit about having the insurance company own your medical records?

    Then there's this interesting analysis of quality and cost:

    Healthcare is not like buying a car. If you want leather seats in a car, this costs more because leather costs more than plastic. If you want a TV set with a bigger screen and more features, that is more expensive; it takes more circuits, more material, and so on. Healthcare is very different, especially today when we already treat virtually every medical condition in some way. Most of the time, the best quality healthcare is also the lowest cost care. The reason is that the lowest costs arise when the patient stays healthy, or gets healthy faster.

    If you get the diagnosis right, you save a lot of wasted and unnecessary treatment, and costs go down. If you avoid making mistakes, costs go down. If excellent surgery allows the patient to go home sooner, costs go down. If you actually cure the disease, the patient does not need to have any more office visits or drugs, and so on, as we discuss extensively in the book. Of all the fields we have worked in, this is the field where the notion that quality is free is the most powerful.

    There's just one problem with this, or maybe it's really two problems. Not all disease are curable, and not all diseases are preventable. The number one cause of disease and death is aging, and we can't do anything to reverse that, although there are those who are trying their best. Many times, what you end up needing is not someone who can cure you, but someone who can help you navigate the ups and downs of chronic illness. So you don't have to walk that lonesome valley by yourself. Insurance companies don't come immediately to mind as the best choice for that role.

    P.S. I've always suspected this:

    In Massachusetts, state government discovered that a significant proportion of the uninsured had incomes of $90,000 a year or higher.

    The problem with our healthcare industry isn't in the delivery, it's in the affordabilty and financial structuring of the system.

    posted by Sydney on 7/15/2006 11:25:00 PM 2 comments


    Welcome back medpundit. I have been generally a medblog lurker for a couple of years. I have never commented on your site. I am a practicing physician in a non-profit "integrated health system" for 10 years. I also happen to be on the board of the health plan which is part of that system. Integrated health care means to me that every aspect of healthcare is in one package from insurer, to hospital, to therapist, to physician. In my area, this has allowed the system to get beyond the bottom line in dealing with employers, medicare, and medicaid patients and work on quality of care. Integrated disease management does work to control costs and improve quality of care. Insurers all already know the diagnoses of every patient. Our plan also knows if a diabetic hasn't had a foot exam, or if the HmgA1C is poorly controlled. We educate every one of our new asthmatics to teach them how to stay out of a crisis. I know the children in my clinic are all adequately vaccinated because we keep track of this. Even a large group practice cannot do this without integration with the payer because the payers become interested only in the bottom line. Our patients get better care and we can prove it. Our physicians are rewarded financially and with recognition for their success in controlling risk factors. Our payers have been rewarded over several years with predictable SINGLE DIGIT increases in cost.

    By Anonymous Anonymous, at 1:10 PM  

    Welcome back Syd!

    And I too am distressed at these Johnny come lately amatuers telling us they ahve the solution for health care--and at $100,000 a day too!

    By Anonymous Matthew Holt, at 2:15 AM  

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