Transcript Kaiser Permanente

Multispecialty Group Practice
Leveraging Integration, Partnership
and Physician Responsibility to
Deliver Performance
A 60 Year Journey, With No End in Sight
March 31 2011
Copyright © 2011
Kaiser Permanente
Sharon Levine, M.D.
Associate Executive Director
The Permanente Medical Group
Kaiser Permanente (KP)
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Integrated delivery system (hospitals and clinicians) and financing
scheme – equal partners, separate entities
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Origin as provider “cooperative”
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Operates like a mini “national health system”
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Single funding stream
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Global budget
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Accountable for total health of a population
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Unlike much of US healthcare
Compete in the market for sponsors (employers), members,
physicians, employees, based on:
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Quality
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Member/patient satisfaction
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Efficiency/value
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Quality of professional life
Copyright © 2010 Kaiser Permanente
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Our model
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Social purpose
Quality-driven
Shared accountability for
program success
Integration along multiple
dimensions
Prevention and care
management focus
Permanente
Medical
Groups
Kaiser Permanente: an
integrated model of health
care financing and delivery, a
unique relationship among
three separate entities –
partnership, contract, and
exclusive
Health Plan
Members
Kaiser
Foundation
Hospitals
Copyright © 2010 Kaiser Permanente
Kaiser
Foundation
Health Plan
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KP Operating Model – (1955)
Health Plan
Members
POPULATION
Group/Individual Contracts:
multi-payer, single revenue
stream to delivery system
REVENUE
---------------------------------------------------------------------------------------------------------------------
EXPENSE
Kaiser Foundation
Hospitals
Kaiser
Foundation
Health Plan
Hospital Service
Agreement
Operating Budgets
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Permanente
Medical Group
Medical Service
Agreement
Capitation to the Group
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Kaiser Permanente Model of
Care Delivery
Four Foundational Innovations
Multispecialty group practice: from the beginning primary care and
specialty care co-located partners
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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
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 Aligned incentives, investment mind-set, salary in lieu of fee-for-service
 Reverse economics: health promotion, disease prevention
 Mutually exclusive partnership of equals between
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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.
National
Partnership
Agreement
The
Permanente
Federation, LLC
Articles of
Federation
Regional Health
Plans
Medical
Service
Agreements
/MOUs
Regional
Permanente
Medical Groups
Partnership Within the
Region
Health Plan/Hospital Leader
Copyright © 2010 Kaiser Permanente
Physician-in-Chief
• Common Vision
• Exclusivity
• Joint Governance and Decision-Making
• Aligned incentives
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Integration: “Secret Sauce”
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“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”
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The right care to the right patient at the right time in the most
appropriate setting – safe, effective, efficient error free
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Shared commitment to eliminating functional, structural,
budgetary impediments to efficiency – ongoing effort: behave in
a trustworthy manner
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Rational budget practices: $’s follow the patient
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Aligned incentives across and within entities
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Integration of care and service
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Integration in care delivery:
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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
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Why so important?
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Seamless care – clarity among clinicians about who is
responsible for what
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Ongoing, and constant, collaboration and negotiation about
accountabilities, cross-cutting QI activities
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Care co-ordination for patients with chronic conditions,
patients with complex care needs
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Capacity to address gaps, handoffs – every one owns it
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Aligned incentives, “shared fate”
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“Make, when you can, buy when you must”
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Culture: Shared accountability for
the Enterprise
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Physician responsibility for quality and cost of care –
somewhat unique in US healthcare until very recently
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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
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Accountability exercised through self-managed and selfgoverned medical groups
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Responsibility for clinical care and patient satisfaction, quality
improvement, resource management, design and operations of
care delivery system
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Physician leaders emerge from clinical ranks, then trained in
business knowledge, leadership, and management skills:
professionals leading professionals
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Broad, distributed model for leadership –
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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…
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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
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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
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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
Primary Secondary
Prevention Prevention
Acute
Care
Chronic
Care
…and accountability across the continuum
from prevention to management of acute and
chronic cardiovascular disease
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Investing in Primary
Prevention
Primary Secondary
Prevention Prevention
Acute
Care
Chronic
Care
Delivering the benefits:
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modify lifestyle
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increase HTN control
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smoking cessation
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decrease LDL cholesterol levels
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Primary Prevention
Increase Hypertension Control
Dissecting the process, making the process clearer and
easier…enables action
Action
Check
Treat
Repeat
Description
Outcome
Was BP taken and recorded?
Documentation
Was BP high?
The denominator
Was treatment intensified ?
Upward titration of
dose and/or
medication type
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
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Primary Prevention
NCAL Leads in Smoking Cessation
Spectrum of Cardiac Care
Adult Smoking Prevalence 2002 and 2005
Adult Smoking Prevalence
2002 vs. 2005
25%
23.0%
20.9%
% Adult population who currently smoke
20%
10%
16.4%
15.2%
2010
2002
12.0% Target
15%
12.2%
7.5%
2005
12%
9.2%
10%
25%
5%
0%
United States
USA
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California
Calif.
Kaiser Permanente
Northern California
Healthy People 2010 Target
KP(NCAL)
SurveyPopulation
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Crossing the Chasm
Secondary Prevention
Primary Secondary
Prevention Prevention
Acute
Care
Chronic
Care
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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Secondary Prevention
Impact of 2007/08 improvements
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Additional 13,900 patients at LDL target
 430 heart attacks/strokes prevented
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Additional 3,000 patients on statins
 220 heart attacks/strokes prevented
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Additional 2,200 patients on ACEI
 90 heart attacks/strokes prevented
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Additional 7,250 people with Diabetes at A1c <9
 350 adverse outcomes prevented
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Additional 17,495 people with Diabetes have
BP < 129/ 79
 1452 CV events prevented
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Acute Care
Cardiac Disease
Primary Secondary
Prevention Prevention
Acute
Care
Chronic
Care
Delivering the benefits:
 7 Joint Commission Core Measures
 Provide revascularisation to appropriate patients
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ST Elevated MIs are declining
ST Elevated Myocardial Infarction - Age/Sex Adjusted Hospitalization Rates
for Kaiser Permanente, 1998 - 2007
ST Elevated MI
Age/Sex Adjusted Rate per
1000
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
1998 1999
2000 2001 2002
2003 2004
2005 2006 2007
Year
ST Elevated MI
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Improving outcomes
Year
Total 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?
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Multispecialty group practice
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Physician leadership – committed and competent
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Aligned incentives
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Credible clinical champions
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Data that drives improvement – timely, actionable,
information technology
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Capacity for change and speed of improvement
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Patient engagement and activation
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Project management
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Reward/recognition/celebration of success – “Pride4P”
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