Clinical Integration – The Link to Special Relativity

einstein1Journalists ask, ‘What does Clinical Integration look like?’  Like Albert Einstein wrote in 1905, it depends upon the observer.

To the patient, its better care experience due to more appointments, easier appointing and navigating, all information available in the moment of shared-decision-making, and all clinicians seem to know each other and trust each other. And that care experience is predictable and reliable (standardized) regardless of the location in which he/she receives care.

To the system-wide CFO, its higher margins for a single clinical service line or all service lines. For example, the production cost of total hip arthroplasty rises year-over-year at a rate less than the rate of revenue for that procedure. That margin occurred because the docs, nurses, pharmacists, physical therapists, improvement engineers and case managers collaborated to reduce (a) clinically unwarranted variation in physician practice patterns and (b) wasteful team workflows.

To the doctor, it’s better professional fulfillment because she doesn’t have to fight as hard for her patient to receive a prompt, goal-directed consultation in Neurology or well-organized home care following hospitalization. A reduction in the time that elapses between onset of illness and definitive treatment is a reliable marker for Clinical Integration (CI); if cycle time doesn’t fall when compared to baseline, CI wasn’t created  (see ).

To the ICU nurse, it’s fewer terminally ill patients on the ventilator, because the Palliative Care consult was performed 6 days after diagnosis, rather than 6 days after intubation.  And she has 3 physician caring for Mrs. Brown, with one of them conspicuously serving in the role of Attending Physician, rather than 6 docs with no Attending.

To the system quality officer, it’s higher HEDIS scores, better Joint Commission appraisals, and fewer events of patient harm or allegations of medical-malpractice, because of less clinically-unwarranted variation in the practice patterns and workflows for patients with similar conditions.

To the Brand & Marketing Department, it’s more patient testimonials on Facebook for why care at St. Neighborhood is better than care at St. Midtown.  And they have more requests than ever to sponsor branded public events.

To the CEO, its higher margin and marketshare over time (lagging indicators), due to the success of the colossal changes in operations, informatics and culture depicted above (leading indicators).

So the manifestations of Clinical Integration, like space and time, depend upon the observer, just like Einstein said.


Clinical Integration – The Essence

The term is becoming increasingly popular, much like Population Health a year ago ( Journalists are hearing Clinical Integration is necessary for healthcare systems to be successful in value-based payment models (e.g., bundled payments for surgical procedures, Medicare Shared Savings Program for FFS Medicare, or global prepayment in Medicare Advantage). So the next several posts will address various aspects of Clinical Integration.

First, let’s clarify the difference between two similar terms:

Zdenko Zivkovic / Foter / CC BY

Clinical Integration (CI) refers to how geographically separate hospitals, physicians and other healthcare personnel contemporaneously coordinate with each other their separate healthcare activities for the benefit of an individual patient or a cohort of patients.  For example, a middle aged man with acute onset LLQ abdominal pain, fever and constipation is seen by 3 physicians (PCP, Radiologist and General Surgeon) in two locations (rather than three) within a 6 hour period of time (rather than 6 days) that results in a single-stage colon surgery for acute diverticulitis (rather than a two-stage colectomy and colostomy complicated by perforation, sepsis and ICU resuscitation resulting from a 6 day evaluation in a fractionated care system).

Clinically Integrated Network (CIN) refers to financially separate healthcare providers (e.g., hospitals, surgical centers, physician groups, home health agencies) that form a shared legal entity that enables single-source contracting with payors, yet is protected from anti-trust prosecution, in accordance with the 1996 DOJ / FTC rule governing CINs.  The stated purpose of CINs is to facilitate Clinical Integration (CINs do NOT create CI, at best they facilitate its creation). In practice, many just raise local market prices without achieving significant improvement in clinical outcomes (several articles to read for additional information, but here’s something recent

The best litmus test for whether true Clinical Integration is being advanced in a particular conversation is to ask this one question: ‘Will the contemplated operational, informational or cultural change reduce the duration of time that elapses between onset of illness (in the case above, acute diverticulitis) and definitive resolution (in the case above, a curative operation)?’  That’s how value is generated for the patient (avoidance of sepsis, intubation and rehab) and delivery system (lower total cost of care, higher brand).

Population Health – the how

I continue to hear strategy pundits say they either don’t know what population health means or that population health doesn’t exist.

If they are confused by the definition or existence of population health, they’ve been asking the wrong people. Clinicians who have actually delivered Population Health at the bedside or in the exam room, rather than individuals who’ve merely read about it, are the better sources for understanding value-based healthcare.

Here’s my proof:

  1. If we define population health simply as lower total cost plus higher quality, and
  2. If we accept the AHIP / NCQA / Consumer Reports data showing which health systems consistently deliver the highest quality outcomes, and
  3. If we accept years of proprietary Aon-Hewitt data or other observations that Kaiser Permanente (KP) produces a 12-25% lower total cost of care than local competitors when benefit-to-benefit comparison is accomplished, then
  4. We can say not only is KP an excellent example of Population Health, it’s been doing it successfully for 75 years, ever since Dr. Sidney Garfield and Mr. Henry Kaiser began prepaid healthcare (Dr. Garfield received 10-cents per week for each employee to prevent and treat illness and injury, improving the lives of those hardworking men and women).

So the assertion by Nate Kaufman and others that population health is vaporware is not supported by the evidence.

How Kaiser Permanente (KP) does what it does is the real insight, the real question.  The how is clearly not easily transferable; otherwise KP’s local competitors would compete more effectively for top honors.

I also hear assertions that how KP does what it does is due to care protocols, or a single enterprise-wide EMR, or that Permanente physicians are employed. In fact there are many delivery systems in the US that have one or more of those attributes, and some that have all three of those attributes, yet their performance is variable.

Instead, I assert that how Kaiser Permanente does what it does is due to physician practice patterns that differ substantially from fee-for-service (FFS) and that those practice patterns are the result of (1) physician leadership, (2) physician culture and (3) systemic workflows that reduce the duration of time between onset of illness and definitive resolution of its cause.

Improving practice patterns is hard for any health system, and real physician leadership is a requisite.  That’s not easily understood by persons who have not led physicians.

Adult Vaccination Rates – another missed opportunity by the media

Mr. Paul Galewitz of USA Today missed an opportunity in his article last week ( to do something The New York Times and The Wall Street Journal routinely do … provide insight to the lay public regarding what really works to improve healthcare outcomes in the US.

Lance McCord / Foter / CC BY-NC-SA

Mr. Galewitz very appropriately calls out the low US vaccination rates in seniors for influenza (65%), varicella (24%), pertussis (50%) and pneumococcus (60%), but fails to report on the well-published science of what health systems can do to make those rates higher.

Instead, Mr. Galewitz uses his airtime to quote doctors who believe (a) it’s the patient’s responsibility to know what vaccines they need (Dr. Robert Wergin, president of the AAFP), (b) billing Medicare administrators is complex (Dr. Reid Blackwelder, chairman of the AAFP), or (c) the main reason for the low vaccination use is the lower effectiveness of adult vaccinations when compared to childhood vaccinations (Dr. Bruce Gellin of HHS).  Ugh.

Here’s what Mr. Galewitz should have reported:

“Every year, 5% of the health systems and doctor’s offices in the US achieve the highest vaccination rates in the country (for example, see any of the 6 Kaiser Permanente regions, for both adult and childhood vaccinations).  That begs the question, ‘What are those doctor’s offices doing that the bulk of US physician practices are not?’  The healthcare industry has known that answer for the last 15 years, yet it hasn’t spread those best practices.  Why is the spread of best practices so difficult for the US health system?”

Anyway, here’s the list of what works for adult vaccinations (see sources below):

  1. Non-physician staff (receptionists, MAs, LPNs, RN’s) assess vaccination needs for each patient prior to the physician walking into the exam room
  2. They communicate a strong recommendation from the physician to vaccinate, which the physician reinforces if needed
  3. The care-team addresses misconceptions head-on (e.g., “the flu vaccine can NOT give you the flu”; “the shingles vaccine does NOT mean you were a bad person in your younger years” [Wikipedia describes it as a herpes virus]; “What are the barriers to you receiving the vaccine today?”)
  4. Physician-directed nurse protocols provide the vaccination before, during or after the visit
  5. EMR-prompts (such as EPIC’s Best Practice Alerts), provide the safety net

Rather than point to pop culture bling (these days everybody believes Uber will solve the world’s problems), Mr. Galewitz missed an opportunity to tell his readers how to recognize better healthcare when they see it (the list above).  He gets one thing right though – he highlights one practice (University of Pittsburgh Primary Care) that increased its vaccination rates by 40% in one year (!!) by deploying the front office workflows and nurse protocols described above, but he buries that point at the end of the article; most readers probably gave up by then.

Jan 2000 – Am J Preventive Medicine

June 2005 – Hopkins NS, Shefer A, et al.  Am J Preventive Medicine 28:5S

April 2015 –

Population Health – the (im)precision of language

hospitalNo phrase has less meaning in our industry right now than “Population Health” – this coming from the guy leading his firm’s practice in … wait for it … Population Health.

Everyone has a different picture in their head when those two words leave their mouth, yet that is the industry-standard term nowadays to convey “what comes after fee-for-service (FFS)”.  Here are merely the Top Ten most common meanings in the industry when those words are spoken:

10. Telephoning patients for the purpose of convincing them to consume preventive services

9. Disease Registries embedded in an EMR

8. Convince patients to modify their personal choices (usually via financial-pain or -pleasure)

7. Financial Bonuses to physicians for achieving a numerical score on quality metrics or for following a more complex coding and documentation process

6. Binding together physician practices for the purpose of negotiating higher professional fees (CIN)

5. A software bridge allowing a modicum of data-transfer between different EMRs

4. Buying or building more bricks and mortar to capture more patient care (revenue)

3. Convince patients to undergo biometric testing (patient engagement anyone?)

2. Enforcing the use of Evidence-Based-Protocols for common disease states

1. Providers assuming financial risk or gain for the cost of care provided

Those snapshots represent a small number of available tactics at best, and entirely miss the true meaning of Pop Health at most.  Here’s my definition of Population Health – “the manner in which healthcare design necessarily changes, once it is no longer paid for by piece.”

If the healthcare in question uses FFS as the mechanism for payment, by definition it AIN’T Population Health. The purpose of Population Health is to create higher quality care at lower or similar cost (better care experience, less harm, and more reliably favorable outcomes). In my experience, those better outcomes rarely occur and are never sustained over time, if paid for by FFS, particularly in the absence of group physician practice.

In order for care redesign to be funded and implemented by hospitals and physicians, those providers must be paid for what doesn’t happen: the ER visit avoided because the doc stayed late in the office to diagnose and treat the patient’s UTI; the cardiac cath avoided in the 22 year old with a pulled pectoralis muscle because a history and exam pays the same as cath; an admission avoided because the ambulatory physician did a great job of organizing the patient’s care, such that decompensation never occurred.  Spending time with patients, thinking about them and with them, and coordinating their care all take time, and as we all know, time is money. FFS can only account for what does happen (the ER visit, the admission, the cardiac cath); it’s non sequitur in the context of Population Health.

So the next time you hear the phrase Population Health, ask two questions: (1) “What the hell do you mean by that?”, and (2) “Before we go on, do we agree FFS payment of any type is NOT involved?”

1994 v 2014: deja vu or brand new day?

It’s a good question that deserves a good answer: “How can it be a good idea in 2014 to organize the provision of healthcare within a unified delivery system, then pre-pay for that care (a.k.a., population health), when that strategy failed in 1994?”

  1. Population Health was NOT Tried in 1994.  The business premises for the two eras are different: in 1994, revenue was considered variable and unlimited (recall, 13% GDP), so all provider interventions of the time focused upon increasing revenue: buy the doctor’s practice in order to raise billable events per encounter (e.g., implement in-office ancillary testing), raise encounters per day (e.g., change office workflow so the doc sees more patients per day, while spending less time with each patient), and raise cash collected per event (e.g., rev cycle in its totality).  In 2014, revenue is more likely fixed (18% GDP, likely limited by US macroeconomics, and millions of debt-laden households are unable to take on more healthcare debt).  The macro-economics of 2014 demand our industry lower expense trends per person, rather than raise revenue per healthcare event (1994), which Population Health can and will do.
  2. The Root Causes of High and Rising Healthcare Costs are Now Known.  In 1994 the prevailing wisdom asserted that doctor’s professional fees were the root cause of unsustainable cost trends, which led to the capitation of professional fees for a cohort of patients (short-lived popularity of HMO plans). But as I’ve written before, our industry and my profession have always been more successful increasing the number of units of care, than public and private payors have been in reducing the payment per unit.  Indeed, pro-fees per office visit have fallen by 30% during the last 20 years (in actual dollars), while the number of units of care per person per year has risen more than that (scripts per year, imaging per year, ER visits per year, surgeries per year, etc). Unless and until an entity (think health-system behaving as a true ACO) is pre-paid for all care (population health 2014), rather than just the professional fees (1994), care transformation won’t occur, and we’ll be forced to resort to “rationing” healthcare in the US. I’ve written previously about the effects of FFS and obesity on the country’s cost trends.

Some health systems mistakenly believe they can create the recipe of Population Health by buying everything said to be on the ingredient list: employ physicians – check; implement an EMR – check; create the legal structure of a Clinically Integrated Network – check.  But prepayment of healthcare can be financially successful ONLY if one addresses how those physicians are organized (salaried, group practice, with a patient-centered culture), how that EMR is used (just-in-time decision-support tool to empower shared-decision-making rather than a poorly searchable repository for documentation), and how care is actually coordinated across the continuum (simple, but comprehensive and reliable, communication channels and workflows that close the knowing-doing gap).  If wide-spread prepayment of healthcare is successful in the second half of this decade, it will be as a result of deeply understanding how healthcare cost is created in the moment of decision between patient and provider, then designing highly-reliable workflows and aligned payment systems that begin to eliminate the 30% of waste and overtreatment buried in that 18% GDP.



The Problem with Pay-for-Performance (P4P)

New York Times journalist Dr. Aaron E Carroll does a nice job in his July 28, 2014 article describing the industry’s disappointment that a seemingly good idea (paying doctors more money for achieving a goal) yields disappointing results (improvements of 4-6% per metric, if at all, rather than 40-60%).  Let’s go deeper … let’s ask why P4P Quality payments in and of themselves fail to achieve the magnitude of improvement in healthcare outcomes our country needs.

#1 First, Determine the Underlying Problem(s) Causing Underperformance of the Clinical Care. Seldom is the problem a failure of physician motivation to do the right thing for the patient.  So adding more “motivation” (in the form of money) is unlikely to produce breakthrough improvements in outcomes between doctor and patient.  The doctor might focus more personal effort upon those clinical goals associated with monetary incentives, but likely at the expense of other equally important outcomes without incentives attached, achieving no net improvement for the practice. And as I’ve written before (What Role, Money”), autonomy, mastery and purpose are more effective than money at producing discretionary effort among physicians.

#2 Next, Formulate Solutions to those Problems. Discretionary effort is indeed an important component for creating improvement in healthcare outcomes, but other components more so.  The dominant reasons for disappointing rates of improvement have to do with lack of (1) systematic improvement infrastructure (systems of measurement, comparison, accountability to colleagues, process improvement), (2) culture of patient safety and team-based care, and (3) blending the promise of medical informatics to the complexities of healthcare delivery.

#3 Finally, Improvement Activities Should be Centrally Coordinated, but Peripherally Empowered.  A hundred points of simultaneous improvement, each using common methods and validated approaches, creates faster tempo of improvement across a healthcare system than a hierarchical top-down approach of control.

Some will undoubtedly assert that P4P’s disappointing results are due to providing inadequate levels of monetary rewards to physicians, but that point of view doesn’t jive with my observations and experiences, nor the research from Daniel Pink and others (see Dr. Carroll’s article for additional information).  We need to think beyond money (P4P) if we are to increase the tempo and magnitude of improvement in healthcare.

Three Market-Based Strategies to Prevent Chronic Illness

In prior posts, I’ve asserted that both the individual and society share responsibilities for the prevention of chronic illness (see Individual v Community Responsibility for Health, KP 101: our philanthropy, and A Tour of Trees, among others).  I’ve also described the gap that often exists between what an individual knows he/she should do and what is actually done (The Knowing Doing Gap).

the vitality institute logo

In this post, I’ll combine those themes in the context of the Vitality Institute, a non-profit NGO launched last year seeking the creation of public-private partnerships that promote health (rather than healthcare) and prevent illness (rather than measures to treat it). Instead of arguing my point using the traditional science of public health, however, I’ll use the science of market-based economics, believing the latter more useful when understanding and influencing human behavior. Each example I provide is scalable, from a small to large company or community.

First, Create Supply… of healthy food choices, fitness opportunities, and preventive services. I know, I know. Traditional econ says demand precedes supply. But I believe the opposite is true when creating healthy human behavior, because 2 million years of evolution has hard-wired us to prefer simple sugars, dietary fat and animal protein, and the conservation of calories.

atlanta beltline

Public Supply – provide multiple points of entry to multiple green spaces (see Atlanta Beltline); set aside land for future public parks (see Trust for Public Land or Georgia Conservancy); provide subsidies for communities to nurture Green Markets and Buy Local campaigns; correct the imbalance of supply of unprocessed ingredients (i.e., grocery stores) and processed food (i.e., fast food restaurants) in low socioeconomic communities; create bike and pedestrian space (see TED Talk of Janet Sadik-Kahn, NYC DOT under Mayor Bloomberg, Atlanta Beltline); spread Power Up for 30 in our public schools (see GA Shape); and embrace certain provisions of the 2010 ACA (preventive care has no co-pay).

nyc bike and pedestrian lanes

Private Supply – corporate subsidies of gym memberships or Zumba classes; provision of showers and locker-rooms in the building; change the contents of vending machines; create non-smoking campuses; arrange for healthy food trucks during lunch; build on-site health clinics;  sponsor nutrition classes and flu-vaccine fairs.

Second, Create Demand… for those good choices. Wouldn’t it be cool if we changed our worship of beautiful appearance to worship of healthy behavior?  I’m told some women do indeed prefer salad-eating, gym-going men.

Public Demand – insist grocery stores provide the provenance of produce; create compelling advertising and marketing campaigns that express the benefits to individuals of buying local (think of the successful Made in the USA campaign); revise the school lunch program to provide healthier choices, then make those choices more appetizing to kids (yes, it’s been done successfully);

buy local

Private Demand – sponsor participation in fitness or philanthropic programs like the annual KP Corporate Run Walk, AHA Heart Walk and Komen for the Cure; sponsor corporate “challenges” like the TSPMG 21-day Vegan Challenge, or one of the biggest loser competitions;

Lastly, Facilitate Consumption … of those good choices.  Seldom do we behave in healthy ways merely because those choices are available, coupled with the knowledge those choices are “good for us”. Our belief systems, borne from our past experiences, dictate our behavior much more than “perceived choice” or “possession of knowledge about the potential benefits of the better choice”. Those better choices must align with our individual, immediate feelings and benefit our individual, long-term interests, whatever they are.

weight of the nation

Public Consumption – make the public green-space safe at all hours of the day; make city-bike programs easy to use and affordable; ensure the safety of pedestrians and cyclists on city streets; halt the subsidization of high-fructose corn syrup (watch Weight of the Nation), and perhaps begin a modest subsidization of fresh produce; create funding for infrastructure that reduces commuting time (such as the 2012 Georgia Transportation Referendum), thus increasing discretionary time for fitness or food preparation.

Private Consumption – employers can provide podometers and incentives to employees to “consume” fitness or proven preventive screenings; healthcare providers (physicians, hospitals and delivery systems) should prove that a specific level of in-year employee consumption of their employee’s good choices will guarantee for the company an equally specific decrease in healthcare costs or increase in profitability.


In my market-based approach, I’ve deliberately ignored the important area of Reducing Risky Behavior. Institutions such as the CDC, States Department of Public Health, National Transportation Safety Board, NIOSH and OSHA (among many others), have that covered.  But one could summarize all as “abstain from tobacco, avoid excessive alcohol, use condoms, and wear seatbelts”, roughly in that order).

Kaiser Permanente has been a national and local leader in creating and enhancing such public-private partnerships for the betterment of America’s health. Just here in Atlanta, we’ve sponsored the Green Market at Piedmont Park, the Annual Corporate Run-Walk, the Eastside Trail of the Atlanta Beltline, the HBO documentary Weight of the Nation, the 21-day Vegan Challenge, gym memberships for employees, and so on.  More such partnerships and infrastructure are needed in Atlanta and across the US to create the supply, demand and consumption of healthy behavior, if we are to reverse America’s raging epidemic of chronic diseases.

Farewell, KP

At the end of this month, following 20 years of service, I will leave Kaiser Permanente.  For each of those years, I’ve given all I had to the organizations – particularly during the last ten years.  It’s simply time I do something else.

I’m proud of what we have built together:

We’re #1 in Quality in the state every year, now nine years running, and one of only three Medicare Advantage plans east of the Mississippi that has earned the coveted 5 STARS.

We are a medical group with a wide range of specialties, broad capabilities in analytics and the science of improvement; led by physicians, professionally managed.

And a medical group that works hard to get better every day. 

My decision to leave has nothing to do with our business in the Georgia Region.  Our care model and quality results are the envy of the Georgia market. 

Rather, it’s time I use my experience and skills to make a difference “out there” – beyond KP and beyond the Georgia market.  I’ve accepted a role with Huron Consulting, headquartered in Chicago.  Huron has a well-earned reputation for providing sustainable operational, financial and work-flow solutions to healthcare providers, intently listening to and serving its clients.   Huron also is a cultural fit for me – a collaborative team of hard-working consultants that enjoy helping clients.  I hope to help the industry transform from “fee for service” to “fee for value” and create safer, more effective, and patient-centric care.  That’s been my mission since my days in training.  It’s why I made KP my home these 20 years. 

I’d like to think I’m leaving our Medical Group in better shape than I received it.  And, as proud as I am of this organization, the next EMD will make it even better.  Please show him or her the same support, the same enthusiasm, the same high commitment to excellence and continuous improvement that you’ve given me. 

In these final days, I’m thinking of my happiest moments here… the time spent at the bedside with you, my trusted colleagues, together figuring out our patient’s illness and what you and I were going to do about it… documenting incisive medical reasoning… using evidence-based medicine… putting the interests of the patient and family above all others. 

I wish you all well. Thank you for 20 great years.

Kids Must Move

 kid bored

Allow me to ask three questions, each having the same answer, I believe. 

1.       “What is the most important tactic in our fight against childhood obesity?”

2.       “How can we improve childhood learning in the classroom without cramming any more fact-memorization into an already bulging curriculum?”

3.       “What will cause kids to ‘behave’ better during classroom instruction, having nothing to do with teacher-enforced discipline?”

 Exercise. Before and during school.   

kid zumba Nov 2013

Largely as a result of budget constraints and the pursuit of higher Standardized Test Scores, most schools have eliminated exercise (“PE”) from the student’s day.  Bad idea.

 Sope Creek Elementary School in Cobb County has reintroduced exercise into the school day, mostly before school, but yes, even at the expense of some classroom time during the day, improving test scores and classroom behavior along the way.  Any good parent knows that kids must move … to behave, to grow, to be happy.  Furthermore, as a community it’s time we attack the greatest threat to current and future generations of Georgians … childhood obesity (for more information, see the state-wide initiative known as GA Shape – we are making a difference). 

 GA Shape logo, Nov 2013

Here’s what Sope Creek Elementary did, organized by Principal Martha Whalen, Coach James Hunt and Coordinator Shawn Maloney:  (1) began a 20 minute Zumba class before school, (2) ensured that all kids, every school day, had at least 30 minutes of exercise while at school, typically in a low-cost activity like running, shooting hoops, or playing hand-ball with a dodge ball, and (3) made it fun (!) for the kids.  All kids that I saw and spoke to, of all ages and backgrounds and body types were thrilled to be moving.  It was way more about the moving than the specific exercise, although everyone loves Zumba.   

 exercise & test results Nov 2013

Here’s what happened: kids now race off the bus to the Zumba room; kids compete with self to improve their running time or distance; absenteeism declined; 5th graders teach the Zumba moves to 4th graders, who teach the 3rd graders; the song/dance repertoire was 5 songs, now 20; the kids are more calm and attentive in class; standardized test scores were already high in the school, and got measurably higher. 

 cardio and scholastics

In fact, as fitness improved for a child (as measured by a simple schoolyard aerobic-capacity test) scholastic aptitude improved (as measured by CRCT tests).    That finding is not new … read “Spark” for more information.

Spark book cover

All ages should heed Sope Creek Elementary’s insight.  We humans must move … to behave, to grow, to be happy … regardless of age, but especially when young.

einstein rides a bike