THE HEALTH CARE DELIVERY SYSTEM AND MANAGED CARE

ORGANIZING THE HEALTH CARE DELIVERY SYSTEM FOR HIGH PERFORMANCE

I. BACKGROUND

Health care delivery in the United States has long been described as a “cottage industry,” characterized by fragmentation at the national, state, community, and practice levels. Despite the federal government’s role as the single largest payer for health care, there is no national entity or set of policies guiding the health care system. States divide their responsibilities among multiple agencies, while providers practicing in the same community and caring for the same patients often work independently from one another. Furthermore, the fragile primary care system is on the verge of collapse. This report focuses on the organization of health care delivery at the local level, considering the relationships among physicians, hospitals, and other providers in a community. Not surprisingly, fragmentation at this level is often reflected in patients’ experiences, as illustrated in the fictional cases that follow:

Frank, a 67-year-old male with Medicare fee-for-service coverage, was admitted to the hospital for an acute exacerbation of heart failure. During the week following his discharge, he tried to schedule a visit with his primary care physician (PCP), as he thinks he was told to by the hospital staff, but he somehow let it slip. Six weeks after he left the hospital, his shortness of breath was getting worse—he could barely make it across his bedroom without stopping to rest, and stairs were out of the question. During Frank’s first post-hospital visit with his PCP, she could not find a copy of his hospital discharge summary in the stack of papers that make up his chart. When Frank shows her the medications he was discharged with, she becomes frustrated and worried because she cannot reconcile them with the medications from her primary care clinic’s chart. Fearing that she cannot safely stabilize Frank at this point, she chooses to readmit him to the hospital.

There are two clear shortfalls in Frank’s case: the lack of care coordination and support as Frank made the transition from hospital to home, and the information gaps in the paper medical records in his PCP’s office. Although discouraging, Frank’s case is typical. Among Medicare beneficiaries, 17.6 percent of hospitalizations result in a readmission within 30 days and, of those, about 75 percent are potentially preventable. Hospitals only provide a simple intervention—giving written discharge instructions for heart failure patients—to about two-thirds of U.S. patients; far fewer hospitals provide a full care transition program. The lack of coordination between hospitals and ambulatory care teams is exacerbated by the scarcity of electronic medical records, making tasks such as medication reconciliation more difficult. As of early 2008, less than 15 percent of physicians used electronic medical records in ambulatory care settings.

Sally is a 42-year-old woman with type 2 diabetes who faithfully sees her internist several times a year. Each time, she complains of a new ache or pain, which then becomes the focus of the visit. Her doctor is a solo practitioner, whose primary interactions with other physicians are during occasional grand rounds and medical staff meetings at the local hospital and a week-long educational conference every few years. One day, the doctor receives a letter from Sally’s insurance company saying that, in the past two years, she has not had several of the screening tests that are recommended for diabetics, including screenings for kidney and eye disease that can be long-term complications of diabetes. The doctor knew that these were recommended tests for patients with diabetes. When he reviewed Sally’s medical record, it took him 15 minutes to confirm that she in fact had not had these tests in over two years.

Sally’s doctor is trying his best, and his knowledge of the basic management of diabetes is up-to-date. Yet, he missed two important tests for Sally—a common occurrence. According to data published in 2006, among commercially insured diabetes patients, only 55 percent had the recommended eye exams or tests for kidney complications. The critical factor in this doctor’s error of omission is that he did not have a system in place for tracking and delivering appropriate care. This could have been addressed by participation in a quality improvement initiative, or implementation of an electronic medical record system with disease registries, care reminders, and clinical decision support. However, as a solo practitioner, this doctor is markedly less likely to take either of these steps than are physicians in larger practices.

Trent is a 33-year-old investment banker who, apart from mild asthma, is fit and healthy. His asthma is usually well controlled with inhaled steroids and the use of his rescue inhaler about once a week. This winter, he caught a cold that had been going around his office, exacerbating the symptoms of his asthma. Although he could get by, he was very uncomfortable and relied on his rescue inhaler every four hours. He phoned his doctor’s office to try to get an appointment after work or on Saturday, but was frustrated because there was a wait of a few weeks for the limited times that the office had after-hours appointments. This being a very busy time at work, he didn’t want to take sick time to see his doctor during regular office hours, so he decided to “ride it out.” However, by Sunday, he had become increasingly uncomfortable. He tried calling his doctor’s office for advice, but he got an answering machine directing him to the emergency room for “medical emergencies.” Trent was not sure this qualified but, not knowing what else to do, he went to his local hospital’s emergency room. After waiting five hours to see a doctor, he was treated with an albuterol nebulizer, given a prescription for oral steroids, and sent home.

Like Frank and Sally, Trent’s experience is not uncommon. A recent survey of health care experiences found that 60 percent of U.S. patients found it difficult or very difficult to get care on nights, weekends, or holidays without going to the emergency room. Although Trent did not end up hospitalized, this happens frequently among more fragile patients who do not have optimal care management and access to ambulatory services. The frequency of such “ambulatory care–sensitive” hospital admissions varies widely across the United States. For example, there is a fourfold difference between the top-performing and bottom-performing states in rates of admission for pediatric asthma, suggesting that many of these admissions could be prevented.

These three cases illustrate some of the shortfalls in our health care delivery system, reflecting its fragmentation and disorganization. If this is not how we want health care to be delivered, what do we want and how will we get it?

II. HOW DO WE WANT HEALTH CARE TO BE DELIVERED?

In a more organized health care delivery system, Frank, Sally, and Trent would have markedly different patient experiences:

· During his hospitalization, Frank would be actively engaged in planning for his care after discharge. His discharge plan would consider his medical needs, as well as needs for clinical nursing, physical therapy, and help with daily activities (e.g., cooking and cleaning). He would leave the hospital with clear instructions about how to manage his illness, and have an appointment with his primary care practice scheduled for soon after discharge. A nurse, physician, or other clinical care manager would check in with him on a daily basis for a few days after discharge. He might even be given equipment to let his care team remotely monitor his medical status. During his first post-discharge physician visit, the details of his hospitalization would already be in his electronic medical record, and his primary care team would have communicated with the hospital team to coordinate a treatment plan. Frank would have avoided another hospitalization, and enjoyed a better quality of life.

· Sally’s physician and other office staff would have participated in a quality improvement collaborative with other practices to improve their care management processes, and they would have an electronic health record (EHR) system to help optimally manage Sally’s care. The EHR would have reminded both Sally and her physician to have the recommended tests. In addition, Sally’s physician would be tracking over time performance indicators based on evidence-based clinical guidelines for all of his diabetic patients, and working with other practices to learn how to achieve benchmark performance. With better care, Sally would be more likely to prevent long-term complications associated with diabetes.

· Trent would have been able to schedule an evening or weekend appointment when he needed it. Although his regular doctor may not have been available every evening or on weekends, there would always be a physician or other clinician who has access to Trent’s electronic medical records. Trent would have been able to avoid a costly emergency room visit and enjoy a quicker recovery from his asthma exacerbation.

In each of the cases, someone—a person, practice, or other organization—would be clearly accountable for the total care of the patient and would ensure that the patient receives high-quality, patient-centered care. In short, an ideal health care delivery system would be organized to have the following attributes:

1. Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.

2. Patient care is coordinated among multiple providers and transitions across care settings are actively managed.

3. Providers (including nurses and other members of the care team) both within and across settings have accountability to one another, review one another’s work, and collaborate to reliably deliver high-quality, high-value care.

4. Patients have easy access to appropriate care and information, including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients’ needs.

5. There is clear accountability for the total care of the patient.

6. The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.

Each of these attributes is discussed in more detail below.

Attribute 1: Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.

It is critical that providers have access to a patient’s full medical history at the point of care in order to deliver the most clinically effective and efficient care. To have this information available in real time, the most feasible approach is to implement interoperable electronic health record systems. Patients also should have access to their medical records, either through a portal to their provider’s EHR system or through a direct transfer of information to patients’ personal and portable health records. In addition to providing timely and relevant clinical information, EHRs have tools to support providers, including clinical decision support systems, reminders for preventive and other routine services, disease registries for population management, and e-prescribing.

Systematic reviews of the literature have demonstrated the potential for health information technology to transform the delivery of health care, making it safer, more effective, and more efficient. EHRs, when successfully implemented, improve the quality of care by increasing adherence to clinical guidelines, enhancing providers’ capacity for disease surveillance and monitoring, and reducing medication errors. In terms of controlling costs, in addition to efficiencies gained from better care management and reduction of duplicative tests, EHRs can improve administrative efficiency. Practices that have implemented EHRs report savings from reduced transcription services, decreased labor and supply costs for chart maintenance and creation, and decreased physical space requirements for medical records.

Attribute 2: Patient care is coordinated among multiple providers and transitions across care settings are actively managed.

As patients navigate through our health system, they see multiple providers (e.g., primary care providers and specialists, psychologists, social workers, and physical therapists) across different settings (e.g., hospitals and physician offices). It is therefore critical that their care is coordinated, and that transitions among care settings are actively managed. Without such management, patients are likely to be frustrated, medical errors are more likely to occur, and unnecessary or avoidable utilization of health care services will increase.

There is strong evidence that, if properly implemented, systems of care coordination could improve health outcomes and reduce costs, especially for patients with complex care needs. In North Dakota, MeritCare Health System and Blue Cross Blue Shield of North Dakota collaborated to conduct a chronic disease management (CDM) pilot program that linked diabetes patients to a CDM nurse in their primary care clinic. This team-oriented approach to coordinating diabetes care resulted in a significant increase in the receipt of recommended care and improved clinical outcomes, including better control of blood sugar and cholesterol, lower tobacco use, and decreased hospital admissions and emergency department visits. Total costs per member per year were $530 lower than expected in the intervention group, based on historical trends, saving an estimated $102,000 for 192 patients in the pilot.

Geisinger Health System has used coordination within a primary care setting through its Advanced Medical Home program. There is great interest now in the “medical home” concept, which is an approach to providing primary care that is accessible, continuous, comprehensive, patient-centered, and coordinated. At Geisinger, patients at high risk for disease complications are assigned a nurse case manager, who is employed by the health plan but embedded as a member of the primary care team in local Geisinger clinics as well as non-Geisinger medical groups. The nurse care manager coordinates with patients’ primary care physicians to develop and carry out customized care plans, including instituting evidence-based protocols and conducting outreach and follow-up when appropriate. The nurse also ensures that all patients admitted to the hospital receive timely follow-up care after discharge and analyzes what happened if a patient has to be readmitted. The system has documented improvements in care processes and cost control, such as savings of about $100 per member per month from reductions in avoidable hospital use among diabetes patients.

As with care coordination programs, there is evidence that care transition programs can result in better outcomes and lower costs. In the Advanced Practice Nurse (APN) Transitional Care Model developed by Mary Naylor of the University of Pennsylvania, APNs follow up with hospitalized heart failure patients after discharge to provide customized care in their homes. A randomized clinical trial of this protocol revealed increased mean time to first readmission for the intervention group, compared with the control group, and significantly fewer total rehospitalizations and lower mean total costs at 52 weeks after discharge. Together, these changes resulted in a one-third reduction in total Medicare outlays. Similarly, Eric Coleman of the University of Colorado Health Sciences Center determined that patients and their caregivers who received tools and support from a nurse “transition coach” upon hospital discharge were significantly less likely to be rehospitalized. Using his Care Transitions Measure, Coleman demonstrated that hospitals that provide adequate information to patients on how to manage their conditions following discharge are significantly less likely to have patients return to the hospital or the emergency room for the same condition.

Attribute 3: Providers (including nurses and other members of the care team) within and across settings have accountability to one another, review each other’s work, and collaborate to reliably deliver high-quality, high-value care.

In an ideal delivery system, providers both within and across settings would work together to reliably deliver high-quality, high-value care. In order for this to be effective, providers must develop accountability to one another. At a system level, accountability would be based on the notion of group responsibility and shared commitment to quality care. This would be evidenced in the performance improvement infrastructure, including peer review procedures, processes for sharing best practices, routine monitoring and feedback of provider performance, and monitoring of overall system performance. Collaborative efforts, supported by effective leadership and shared goals, result in better performance than that of providers working in isolation. For example, large physician groups generally perform better on measures of clinical quality than small physician groups (see Section IVfor additional discussion).

In addition to having a performance improvement infrastructure, it is also important that providers offer team-based care. The Institute of Medicine identified the development of effective teams as one of the key challenges for the redesign of health care organizations, and 88 percent of Americans view doctors and nurses working as a team as an effective way to improve health care quality. For example, the IMPACT program, disseminated by the University of Washington, improves the quality and efficiency of care for patients with late-life depression through collaborative teamwork. Under this model, a depressed patient’s primary care physician works in collaboration with a care manager (a nurse, psychologist, or social worker who may be supported by a medical assistant or other paraprofessional) to develop and implement a treatment plan. A consulting psychiatrist provides weekly caseload supervision to the care manager. If the patient’s condition does not improve (by at least 50 percent after 10 weeks), the consulting psychiatrist suggests treatment changes. In multiple studies, the IMPACT program has been shown to be significantly more effective than usual care for depression in a wide range of primary care settings. A randomized controlled trial found that 45 percent of IMPACT patients had a 50 percent or greater reduction in symptoms of depression after 12 months, compared with 19 percent of patients in the usual care group. IMPACT patients had lower-than-average costs over four years for all of their medical care, a total of approximately $3,300 less than patients receiving usual care, even taking into account the cost of the IMPACT program.

Attribute 4: Patients have easy access to appropriate care and information, including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients’ needs.

In a patient-centered health system, appropriate care should be easily accessible to patients. Beyond having health insurance coverage, patients should be able to access appropriate health care when it is convenient for them; that means offering same-day appointments for urgent care and office hours that extend beyond regular work hours. Providers should be culturally competent, too—that is, they should show respect for and demonstrate understanding of patients’ preferences and their cultural, social, and economic backgrounds. There should also be multiple ways for a patient to enter the health system, such as through convenient retail clinics or e-health visits, as well as through traditional primary care clinics. Finally, patients should have 24-hour access to clinicians to help them navigate the health system for urgent care needs.

There is evidence that patients who receive care in a setting that is well organized and offers enhanced access to providers (e.g., in a medical home) are more likely to get the care they need, receive reminders for preventive screenings, and report better management of chronic conditions than patients who do not receive regular care in such settings.

Attribute 5: There is clear accountability for the total care of the patient.

In our health care system, it is easy to imagine that no single physician, or entity, feels accountable for the total care of a patient, but only for the portion of care they directly deliver. Without accountability for total care, it is easy to ignore care coordination and care transitions (and risk having patients “fall through the cracks”), and to focus on high-cost, intensive medical interventions rather than higher-value preventive medicine and the management of chronic illness.

In an ideal delivery system, some entity would be accountable for the total care of patients, across providers and care settings. The locus of accountability may be with an individual physician, a medical home, or the entire delivery system.

Attribute 6: The system is continuously innovating and learning in order to improve the quality, value, and patients’ experiences of health care delivery.

In an ideal delivery system, providers and health system leaders would be continuously learning and applying their knowledge to improve the quality, value, and patients’ experiences of health care. Not only would innovation drive performance improvement for existing processes, but also new structures and models of care would be tested to deliver greater quality and value to patients (e.g., the disease management and care coordination models described above).

III. IS ITACHIEVABLE?

Despite the overall fragmentation of the health care delivery system, there are pockets of innovation and high performance in the United States. The Commonwealth Fund, in partnership with Issues Research, conducted case studies of 15 diverse types of delivery systems that have been widely recognized as examples of high performance (see Appendix and Exhibit 1). The case studies examine the achievements of the delivery systems on the attributes we have identified for ideal health care delivery. The subjects range from fully integrated delivery systems such as Kaiser Permanente to large multi-specialty group practices such as the Marshfield Clinic to looser forms of organization such as Community Care of North Carolina. Even among the integrated systems, there was diversity with regard to public versus private systems, whether the system also included a health plan, and the contractual relationships among the partners.

From the case analyses, four important lessons emerge:

· Existing delivery systems have achieved many of the attributes of ideal health care delivery.

· There is more than one approach to organizing providers to achieve these attributes (see box).

· Although there are diverse approaches to organization, some form of organization (i.e.,relationship among providers with established mechanisms for working across providers and settings) is required to achieve these attributes.

· Leadership is a critical factor in the success of delivery systems.

The following sections illustrate how the 15 delivery systems examined in our case studies achieved the attributes of ideal health care delivery. A summary of each health system’s performance on each attribute is found in the Appendix (Exhibit A2).

Patients’ clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.

In nearly all the delivery systems, providers use a shared electronic medical record. Lab results and other tests are available to all providers, regardless of who actually ordered the test. In some systems, such as the Group Health Cooperative, Henry Ford, Geisinger, and Kaiser, electronic medical records have portals to enable patients to access their medical information and make appointments online. The investment in these systems was substantial, both in terms of hardware and software costs as well as training and ongoing support of provider utilization. The resources were either a direct investment by the delivery system or, as in the case of Partners HealthCare, funded in part by a payer’s pay-for-performance program negotiated by the delivery system. In either case, organization was critical not only in getting providers to adopt electronic medical records, but also in creating infrastructure to enable information exchange.

Regional Health Information Organizations or Health Information Exchange Networks may be able to facilitate information exchanges among providers. However—given the demise of high-profile health information exchange efforts such as the Santa Barbara County Care Exchange and the slow adoption of EHRs by physicians not in large organizations—widespread use of EHRs with sharing of information among providers is most likely to occur in organized delivery systems.

Patient care is coordinated among multiple providers and transitions across care settings are actively managed.

Organized delivery systems are working to ensure that patient care is coordinated and care transitions are managed. Several delivery systems, including Geisinger, Group Health Cooperative, and Henry Ford, are developing their primary care sites to be “medical homes,” or centers of care coordination for ambulatory patients. Intermountain Healthcare (IHC) emphasizes the central role of primary care physicians in managing patients’ care, enabling them to treat chronic illnesses in the context of broader health issues. For example, IHC instituted a mental health integration program in which behavioral health professionals support primary care teams in recognizing and treating patients with both physical and mental illnesses. At the Mayo Clinic, every patient is assigned a coordinating physician, whose job it is to ensure that patients have an appropriate care plan, all ancillary services and consultations are scheduled in a timely fashion to meet patients’ needs, and patients receive clear communication throughout and at the conclusion of an episode of care.

In the New York City Health and Hospital Corporation’s Queens Health Network, care managers dedicated to several different clinical areas or settings (e.g., the emergency department, diabetes, heart failure, or HIV) are responsible for identifying high-risk patients and coordinating their care across inpatient, outpatient, and community clinics, with the goal of preventing emergency hospital visits. These care managers operate under a cross-functional care management department.

Even in less-integrated systems, such as Community Care of North Carolina (CCNC), care management is critical. CCNC is a system of 14 regional networks, each of which is a nonprofit organization consisting of essential local providers, county health departments, and social services. CCNC networks rely on case managers, whose core processes are the same across all networks, to help identify high-risk patients, assist in disease management education and follow-up, help patients coordinate their care and access services, and collect data on process and outcome measures.

A systematic approach to coordinating patient care and managing transitions requires some organizing entity.

The mechanism is apparent in a single organization such as an integrated delivery system, since a single organization housing multiple providers and care settings is responsible for all aspects of that patient’s care. Individual providers or small practices that seek to offer well-coordinated care must establish multiple linkages with other providers and settings. These linkages are, in fact, the beginning of “organization.”