The Medical Ad-Hocracy To Integrate or Not... David M. Lawrence, - - PDF document

2012

To Integrate or Not...

David M. Lawrence, MD, MPH

The Medical Ad-Hocracy

“In the first month of her combined hospital and nursing home stay, Mom was cared for by ten physicians..., (and) at least fifty...nurses, ten physical and

• ccupational therapists, and a

host of nurse aides.”

(Health Affairs 22, no. 2 (2003): 238-242)

“...she...developed frustration and cynicism about the health care system... the mixed signals, the delays, the unexplained changes in treatment plans and prognosis, and the uncertainty about when she could leave...”

(Health Affairs 22, no. 2 (2003): 238-242)

✤ Rich Umbdenstock, Executive Director of AHA: ✤ “ONE” ✤ “SYSTEM” ✤ Common: experience, diagnosis and

treatment, processes, communication, decisions, collaboration, support, measurement, accountability, learning, pay/incentives, dispute resolution

✤ A careful balance between standardization

and customization

✤ (what Richard Bohmer calls “iterative

and standardized” care…R. Bohmer: Designing Care 2010)

✤ Transparency: visibility into every step in the

process

✤ Agnostic about where care occurs (best

place) and who does each job (best person)

✤ Technology substitutes wherever possible ✤ Clear boundaries: where “care” starts and

stops

Acute Care Primary Care Pre- Primary Care End-of- Life Care Acute Care Primary Care Pre- Primary Care End-of- Life Care Level One Acute Care Primary Care Pre- Primary Care End-of- Life Care Level Two Acute Care Primary Care Pre- Primary Care End-of- Life Care Level Three

Acute Care Primary Care Pre- Primary Care End-of- Life Care Level Four

So why do it?

BECOME AN ACO?

✤ Competitive Flexibility ✤ Strategic Flexibility ✤ Ethical High Ground…the right thing to do

Why, then? Competitive Flexibility...

✤ highest quality + lowest cost = greatest value...

QUALITY COST you

• thers

you

• thers

Getting there...

✤

Patient-Centered Design

✤

Variation

What care delivery integration can produce...

✤ A measurable cost advantage by reducing unnecessary variation ✤ A measurable, patient-centered quality advantage by reducing

unnecessary variation and designing care for and with the patient

✤ Resulting in a measurable value advantage for the patient, families,

community and payers

✤ And maximum competitive flexibility

Strategic Flexibility...

✤ How care delivery integration positions you in different futures

Three possible futures...

✤ Full capitation and rewards for integrated systems ✤ FFS and fragmentation (status quo) ✤ Consumer-driven Health Care Choice ✤ Government-run system (“single payer +/- single provider”)

Capitation and Integration + ++++ FFS and fragmentation (status quo) ++/+++ +++ Consumer- Driven Choice + +++/++++ futures

STRATEGIC FIT

status quo integration

Ethical Consistency

✤ We want to deliver care that is consistently safe, effective and

affordable for the individual patient, the community, and the nation.

✤ Systems that protect individual physician autonomy and status quo

care delivery model cannot do this.

✤ Systems that focus on collaboration, teamwork, and meticulous

system design for and with the patient can meet these goals, and are ethically consistent with our oaths as professionals and care-givers.

Because?

Thank You