The Harkness Journey

Why Harkness?

• Had been on 3 study trips to see US healthcare: – 2001 ODP network (with Pam and Steve Pashley) – 2003/4 DH fact finding Kaiser and Evercare (with

Steve Dunn) – 2007 Northern Ireland to Kaiser (with Tim Kelsey)

These experiences left me very positively predisposed to further ‘study’ in the US!

• Was working in Trafford with set of physician and management colleagues to develop ‘first principles’ model for integrated care and became involved with Nuffield policy work

• Fellowship based at Stanford with Alan Garber • Now working as Senior Adviser on Health

Reform for Republic of Ireland • Cannot be recommended highly enough -

deserves it’s ‘life changing’ epithet

Journey

• You mean I get to meet these people:

Karen Davis, Mayor Bloomberg, Alan Garber, Don Berwick, Brent James, Elliot Fisher, Larry Casalino, Alain Enthoven, George Clooney, Julian Legrande, Karen Davis, Ken Kizer, Don Light, Jay Crossen, Karl Ulrich – extraordinary fellow fellows!

Highlights

Light, D and Connor, M ‘Reflections on commissioning and the English coalition government NHS reforms’ Social Science & Medicine, 2011, vol. 72, issue 6, pages 821-822 Connor, M ‘Local innovation can’t be driven from the top down’ British Medical Journal, 2011;343:d5719 doi: 10.1136/bmj.d5719 Integrated Delivery Systems and lessons for health reform in England (prepped for submission)

Being published…

The research

There is much more talk about systems (and integration) than clarity about what we mean…

Methodology Research question: Can we be more explicit about step 2? Systems selected following key informant interviews and literature review: Marshfield Clinic, Veteran’s Health Administration, Kaiser Permanente, Intermountain Healthcare All established and mature integrated delivery systems, albeit with very different ‘natural histories’ Semi-structured interviews, publically available and private literature, site visits Work involved c. 37 interviews undertaken at four site visits and meetings with system leaders

Marshfield Clinic

Map of Marshfield Clinic service area (Wisconsin)

Natural histories

Marshfield Original group started in 1916 with 6 physicians Grew organically until the mid-70s when it underwent a rapid expansion through acquiring an extensive network of community based primary care and small group practices (a ‘turn’ to primary care) Very long-standing commitment to EHR with some health records going back to the 1970s and a genetic engineering research facility with 20,000 patients registered with genetic information, blood samples and electronic histories (can trace Germanic family lines…) The clinic is nationally recognised for its ICT and managed to convert its entire clinical system into a paperless operation in three years from 2004 – 2007 and every physician now practices on a laptop – as I directly observed Achieved by far the highest level of savings (>$30m) of any of the 10 PGP demo sites from 2005 – 2010, which it is now investing in getting NCQA accreditation for all its primary care sites as medical homes

The VHA

Map of VHA VISNs

The VHA Established after WWI to provide care for veterans suffering as a result of their military service (though some accounts trace its roots to the first federal military veterans hospital in Pittsburgh in 1778) Its beneficiaries expanded massively after WWII, Korea and Vietnam and a series of high-profile quality problems led to a major loss of confidence in the 1980s and 1990s Underwent a major re-engineering and transformational change from 1995 – 1999 under the leadership of Ken Kizer (not least based on universal primary care) RAND study (04) found VHA outperformed the rest of US healthcare on 294 measures of quality… CBO (09) said care ‘compared favourably’ with that given by non-VHA providers Especially noted for its extraordinary VistA open-source EMR and very strong relationships with academic centres for research and physician training

Natural histories

Kaiser Permanente

Map of Kaiser Permanente facility locations

Natural histories

Kaiser Permanente Founded in 1942 by Henry Kaiser and Sidney Garfield from a history of industrial health management associated with the Colorado River Aquaduct, the Grand Coulee Dam and WWII shipbuilding. From its inception was closely associated with a primary care model – developed to offer efficient care for workers and their families Lost $770m in failed attempt to write its own IT system with IBM, which led to a new approach, ultimately with Epic Systems, to implement HealthConnect – ‘the largest civilian electronic medical record system’, implemented at a cost of $6bn, or c $500k per physician It has a tri-partite structure of KP Hospitals, the Permanente Medical Group(s) and the KP health plan, seen as ‘three legs of a stool’ and fully aligned strategically Scores highly in State and national quality reports – in 2009 becoming the first HMO to get 4 out of 4 stars in the ‘Meeting National Standards of Care’ category

Intermountain Healthcare

Map of Intermountain Healthcare facility locations

Natural histories

Intermountain Healthcare Initially formed as the entity for the LDS to spin out its hospitals in the mid-70s Experienced significant ‘mission conflict’ (Brent James’ term) in implementing cost control strategies in the 80s and a failed venture into the insurance market Formed its medical group only in 1995 and its differentiation into a systematically managed, high-quality system dates from this time – 75% primary care at inception Like Marshfield, has a long history of EHR going back to the 70s and is presently engaged in a massive renewal of its system, partnering with GE, into which it is incorporating standardised workflow associated with agreed models of care Only system to be ranked No 1 out of 600 5 times in the Modern Healthcare/ Verispan annual rankings (in 2000, 03, 04 and 05… it came second in 01, 06 and 07) (wonder what happened in 2002) Has developed and runs the world-class Advanced Training Programme for clinicians in quality improvement

5 ‘structural similarities’ of the IDSs studies

1) Mapping of population to primary care physician 2) Systematic accountability for PCPs as providers

in the context of integrated system 3) Shared governance (PCPs and specialists in the

same business) 4) Multi-specialty physician group controls/shapes

hospital services/ contract using make or buy 5) Physician-led commitment to information

systems

Popu

latio

n

Prim

ary

Care

Mapped to

Shared governance

with

Spec

ialis

t tea

ms

Can we discern a ‘strong archetype’?

EHR

Hos

pita

l ser

vice

s

Virtual or actual

control of

Domain defined by

Overall physician control

GP registered

list

Commissioning, compettion and choice make MSMGP difficult or impossible

No ‘skin in the game’ for GPs or consultants thus left to management cadre

Strategic Heath Information Teams (Electronic)

GPs only formally accountable for primary care piece

First, by establishing Clinical Commissioning Groups in the same evolutionary line as PCGs and PCTs, the reforms persist in placing GP leaders on one side as ‘purchasers’ with the hospitals on the other side as ‘providers’. This oppositional structure is likely to end up in the same space as its predecessors – with weak control and little in the way of integrated working. Second, the particular emphasis on ‘Any willing provider’ and ‘patient choice’ means that it is difficult to conceive how GPs and consultants could form anything like the multi-specialty physician group entity that lies at the heart of the successful integrated systems in the US without falling foul of the regulatory regime. This makes it impossible for the right locus of integration to be developed that can truly consider the cost-benefits of ‘make or buy’ decisions. Since both the development of CCGs and the commitments to competition and patient choice in these particular ways remain cornerstones of the coalition plans, it is doubtful that they will produce anything like clinical integration that has been successful in the US.

CONCLUSION