By Anthony Shih, M.D., M.P.H.
The list of delivery system reform efforts that are currently being designed, planned, and implemented, in both public and private sectors, is impressive. We have patient-centered medical homes, health homes, accountable care organizations, initiatives to reduce avoidable rehospitalizations, programs to improve transitions to and from nursing homes, and health information exchanges, to name just a few. Considered individually, many of these efforts may potentially both improve health care and bend the health care cost curve. But how do we view, reconcile, or make sense of these, as a whole? Are they competitive? Duplicative? Counterproductive? I would say no. Instead, I believe that they are synergistic strategies to move us toward the higher goal of a more "organized delivery system."
Fragmentation is one of the fundamental problems in U.S. health care: it is pervasive at the national, state, community, and provider practice level. Its symptoms include frustrating and dangerous patient experiences; medical errors, waste, and duplication; variable and suboptimal overall quality of care; and use of high-cost intensive medical intervention over higher-value primary care. In 2008, the Commonwealth Fund Commission on a High Performance Health System laid out a vision of an ideal organized delivery system that aims to improve the entire continuum of care in a geographic area:
- Patients' clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.
- Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.
- Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other's work, and collaborate to reliably deliver high-quality, high-value care.
- 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.
- There is clear accountability for the total care of patients.
- The system is continuously innovating and learning in order to improve the quality, value, and patients' experiences of health care delivery.
Notably, the report also demonstrated that there are many models to achieve better organization (i.e., not all have to follow the Kaiser Permanente or Geisinger Health System approach, which may be unrealistic for many regions of the country).
Although the report laid out broad policy interventions to help achieve better organization, such as payment reform and promoting health information technology, it did not specify what programs and projects to undertake to get there. The new delivery system reform efforts are the specific initiatives—the building blocks—of a more organized delivery system. Creating strong primary care infrastructure through promotion of medical homes; building the ability to exchange information seamlessly through promotion of electronic medical record meaningful use and health information exchange; creating linkages to ensure care is coordinated within and across settings, as in our efforts to reduce hospital readmissions; and establishing accountability for populations of patients through accountable care organizations are all key to an organized system. Each of the programs is building bridges between providers within and across settings that will reduce fragmentation.
In this context, however, "success" is not declared project by project (e.g., by transforming all primary care practices into medical homes or by "connecting" all the providers electronically). Each alone is incomplete, and if left alone, may create new lines of fragmentation within the system. Rather, success must be defined in the broader view of organizing the health care system to achieve high performance on access, quality, and costs. If each project is a building block, those working on that project must recognize that their initiative has to eventually fit with the other building blocks.
Why do we want a more organized delivery system? The evidence to date strongly suggests, and I firmly believe, that it is a necessary (though not sufficient) condition to achieve our ultimate goal of high-quality care and better population health, at a reasonable and sustainable cost for all. It is impossible for a non-system to react rationally to policies that support our ultimate goals. With that in mind, pursuing all these distinct programs and initiatives as part of a broader strategy to better organize the delivery system makes a lot of sense.