It already exists thanks to Kaiser Permanente, a not-for-profit health insurer and hospital chain based in California, United States. In this blogpost, I report back from a seminar-led by Kaiser Permanente's Murray Ross and Joy Lewis, and hosted by Reform in London on Wednesday 19th September.
For those of you clinicians and patients who are sceptical of taking home lessons from across the pond, where overall costs are horribly bloated by profit-making insurers and cherry-picking "fee-for-service" providers naming their price, I would advise you to pay closer attention to the high quality of its care, the level of patient satisfaction and the overall efficiency of the Kaiser Permanente operation.
For the fourth straight year, Kaiser Permanente is the only health plan in California to earn a 4-star rating - the highest possible - for overall quality of care by the California Office of the Patient Advocate, and has also achieved the highest possible rating for patient satisfaction. By virtue of its system of prepayment rather than fee-for-service, Kaiser has created a compelling model of integrated, high-quality, accessible health care.
As per Joy Lewis' introduction, Kaiser Permanente has 3 branches: a not-for-profit health plan, a not-for-profit community hospitals and 8 independent self-governed Permanente Medical Groups. With more than 7 million members in California alone and a further 2 million in 6 regions across the US, Kaiser serves a population greater than that of London.
Joy, who is Manager of Kaiser Permanente International, explained that the role of technology within the organisation is as an enabler, and nothing more. It's power depends on the users and the pervading cultures: without engagement from doctors the technology cannot be used to improve clinical effectiveness or improve the patient experience. It boils down to a simple equation:
Large new IT system + Old Organisation = Costly Old Organisation.
Could she have been referring to the NHS Programme for IT?
Murray Ross, Director of the Kaiser Permanente's Institute for Health Policy, went onto describe the role of data as one part of a triad of key components in Kaiser's success. These are:
1) Physician Leadership
2) Mindsets & Behaviours
3) Data & Reporting
The first part of the triad will be very interesting to those who are afraid that data will be used by managers as a malevolent tool to control doctors' behaviour. The overarching principle here is to preserve autonomy at the individual clinician level. Each of the medical groups providing care has an elected physician board i.e. the system relies on doctors leading other doctors. Promising leaders are identified early and each of these are given management training: further enhancing engagement of medical staff.
The second part of the triad refers to the culture of continuous improvement, knowledge-sharing and team-working that has enabled Kaiser to outperform its peers. Over decades, Kaiser has evolved a policy of pro-active, preventative, integrated care over reactive, fragmented care. The popularity of Kaiser amongst prospective physician recruits helps, there being a typical 10 applicants per post: Kaiser is able to pick and choose the most engaged and talented medics.
The last member of the triad is data and reporting. Over the past decade, Kaiser has spent over $4bn on an Electronic Health Record system developed by Epic. The most obvious benefit of this is that doctors can see ALL of their patients' medical information at the click of a few buttons: at the right place, at the right time. But just as useful to the organisation are the "matrix searches" possible on the vast amounts of data. Information can be pulled up by doctor, department, diagnosis and many other dimensions.
There a number of exciting consequences for this including:
- the activity/behaviour of doctors can be measured against peers in real time
- care can be given proactively e.g. diabetes sufferers can be searched and all those requiring foot check/retinal screening/HbA1C check can be approached
- whole populations can be tracked/measured to develop screening programmes.
Of these, the most anxiety-provoking for a British doctor may be the sharing of activity data "unblinded" amongst peers. However, the culture is not punitive, it is more about the development of good clinical practice. Doctors, who are usually all "A" students, naturally don't like coming last, so the mere sharing of data promotes competition by forcing doctors to simply ask: why? i.e. why am I different to those at the other end of the curve? The usual challenges include, "my patients are sicker" or "the data is wrong". Here it becomes especially important that Kaiser is built on physicians leading physicians. Outliers are recognised via a culture of openness and transparency, and, through discussion with and learning from their peers, those outliers improve their clinical practice.
Of course it would be difficult for the Kaiser Permanente model effectively provide high-quality, affordable care without appropriate alignment of incentives. Physicians working in the Kaiser system receive a 10% bonus if both the facility they work in and the individual physician achieves specific quality measures. There are no incentives based on volume, costs, utilisation or other financial measures. This idea is particularly relevant to NHS where the payment system mostly rewards activity.
The presentation closed with the observation that the affordability of latest health care reform in the United States was envisaged to depend on "delivery system reform", and the concurrent rise of the Accountable Care Organisation "...a group of physicians teamed with a hospital with joint responisbility for the quality and cost of care provided to a large (Medicare) population" as an alternative to lowering fee-for-service payment rates. This, according to Kaiser, is what they have already been doing for 60 years and, if successful, will change the way care is organised and delivered in the US.
