Replicating High-Quality Medical Care Organizations

Most agree on the need for restructuring the US health care delivery system and increasing the capacity to provide coordinated care across the illness continuum in a patient-centered fashion. There is strong interest in developing accountable care organizations that have the capacities to (1) monitor meaningfully patient needs and outcomes, (2) use performance indicators for assessment of physicians and other professionals, and (3) implement new forms of reimbursement that result in improved quality while constraining increases in cost. A range of exemplary models are commonly used as examples including the Mayo Clinic, the Cleveland Clinic, Kaiser-Permanente, and Geisinger Health System but these examples are poorly matched to the existing distribution of medical practices and their small sizes.

In 2005-2006, almost half of all physicians practiced by themselves or in partnerships and only 9% were in groups of 11 or more.¹ Group organization in primary care was much the same. The notion that the organizational structures and cultures of the exemplary models can be replicated in even a decade seems unlikely. Major changes in reimbursement can expedite structural changes and aggregation of physicians into larger entities but changing the culture and developing new shared norms of professional responsibility and practice, effective teamwork, and an evidence-based and patient-centered perspective will be a more enduring challenge.

Data from the Dartmouth Atlas and related studies suggest that many of these models offer care at more modest expenditure levels than typical of high-cost areas.² As the advocacy and reasoning goes, transferring the successful approaches used by these settings will substantially improve care and lead to large savings that bend the cost curve downward. The problem is that an established approach for doing so is lacking, potentially leading to resistance and practical problems. A point often overlooked is that the culture of these exemplary centers and care systems developed over time (in some cases over a century or more), and in no case quickly; and the organizations that are admired are the successful entities, often with extraordinary leadership, and not those that failed or faltered along the way.³ In this mix, Kaiser Permanente is a relative newcomer, first sponsored by Kaiser industries in the late 1930s as an industrial health care program for their construction, shipyard, and industrial workers.

Expenditures can be reduced by payment constraints on health care organizations and clinicians and by increasing patient cost sharing. But such crude constraints do not distinguish between appropriate and wasteful care seeking among patients. Nor do they prevent manipulation of reimbursement by health organizations and physicians such as risk avoidance, shifting responsibility to others, increasing volume, or up coding. The changes needed to realistically reorganize the provision of care requires reconstituting the norms and culture of the work of physicians and other professionals through their buy-in and centrality in change efforts.

Physicians are dissatisfied with what they experience in chaotic care environments.⁴ There is ample indication that workflow is more harmonious when physicians and other health care professionals participate in establishing care processes, when professional autonomy is valued and preserved within the context of organizational accountability, and the norms and culture support professionalism. An organizational practice particularly disturbing to physicians involves approaches that tie their remuneration to doing less than they believe is necessary for their patients.

One concept receiving increasing interest is sharing savings with physician groups that meet predetermined quality criteria while attaining cost-containment targets.⁵ A strong collaborative organizational culture is needed to advance such goals, and medical leaders view 4 elements as essential: strong focus on mission; strong leadership; good measures and feedback of results including clinical quality indicators; and tools for care coordination, operational system support, and an outstanding clinical information system.⁶

Abundant evidence and experience demonstrate that financing and reimbursement significantly shape care processes and priorities. There is considerable advocacy for abandoning fee-for-service, paying for performance, bundling payments for episodes of care to encourage coordination and continuity and avoid expensive hospital readmissions, and to increasingly use more sophisticated risk adjustment payment to reduce risk selection. All of these approaches have promise, although advocacy commonly neglects the limitations. Fee-for-service, capitation, and salary, depending on the organization and culture of the care system, can distort good practices. But any of these payment approaches need not have perverse effects if they are embodied in a well-established physician group culture and clear normative expectations in which clinical and managerial leadership are evident.

Other experience indicates that physicians prefer any system they are accustomed to if remuneration is seen as fair.⁷ Few organizations use these pure payment types without modifications and additional incentives to encourage initiative, productivity, performance quality, and loyalty to the organization. The distinction between how these organizations are reimbursed and how they pay their professionals is important. Capitated organizations often use a variety of payment arrangements depending on clinicians' capacity to manage financial risk or in response to recruitment and retention needs.

Improved understanding is necessary for building the requisite cultures given the diverse practice arrangements, differences in professional and regional culture, and resistance to change. Nevertheless, there is considerable agreement about essential tools, including development of information technology, electronic medical records, and system connectivity; better dissemination and use of evidence for making decisions; and improved clinical measures with continuing feedback to clinicians. Better organized teamwork, coordination, and collaboration also are needed. Although financial and organizational coordination are important, the ultimate test is success in clinical integration, which is the most challenging of the changes needed.⁸

Building accountable care organizations that can achieve clinical integration across the continuum of illness is a formidable task given the underdeveloped building blocks. Shortell and Casalino,⁹ knowing that large multispecialty groups will develop only slowly, have suggested that most physicians can be involved by building on such existing entities as hospital medical staff organizations, physician hospital organizations, interdependent physician organizations, and health plan networks. Appropriate financial incentives can expedite the transition to accountable care organizations. Nevertheless, overcoming the operational requirements is challenging with little detailed knowledge or strategies of achieving these goals.

Successful development of accountable care organizations is unlikely without a well-organized system of primary care.¹⁰ There is now much interest in reviving older conceptions under the rubric of medical homes that would help manage the needed communication and coordination. The idea of paying for now-neglected cognitive, management, and instructional components of care appeals to primary care physicians but the business model that will facilitate a robust primary care sector and successful recruitment of young physicians remains uncertain.

Achieving a patient-centered and professionally satisfying culture and closing the quality chasm in cost-efficient ways depend on accountable organizational arrangements, strong primary care, and effective team performance. Participation of nurse practitioners, physician assistants, and other professionals is essential; and the emerging culture of these settings must ensure that the roles and contributions of all participants are coordinated clearly and respected. Innovative approaches to primary care are needed along with new ideas for how physicians and other primary care clinicians can be educated to work together effectively and to fill their roles in thoughtful and more satisfying ways.