Health Care Reform: Chasing Kaiser

As health care providers and policy wonks cogitate on MACRA and eligible clinicians devise how they might reasonably manage their responsibilities under MIPS or APMs, I wonder if setting the conditions to accelerate the growth of integrated care delivery and financing organizations, like Kaiser, may help us collectively achieve quality and cost-of-care objectives faster than large-scale, nationwide quality measurement and incentive programs.

The aim of the industry seems straightforward enough: make changes to reduce costs and deliver higher quality care.  Value-based programs of many sorts seem rightly instituted when reviewing comparative quality and cost research from other developed countries; although in execution, especially at nationwide scale, the programs can be confounding to those involved for numerous reasons not mentioned here. 

With a plethora of value-based incentive programs in flight, the relationship between government and commercial payers and providers become analogous to employers overseeing employees - measuring aspects of performance and rewarding or penalizing based on the performance.  One difference between a typical employment scenario and the quasi-experimental value-based relationships between providers and payers is that the providers are often not employed by the payer. 

The exceptions are the organizations with integrated care delivery and financing.  As both a provider organization and a payer that ideally insures most of the patients who are cared for by the provider organization, interests at the highest corporate level are unified.  Someone at the top gets to make a decision if and when the two major subordinate components of the organization don’t agree or have diverging interests. 

As compared to Federal programs, these integrated delivery networks (IDNs) aren’t limited to collecting a finite number of quality measures during a given year, to coalescing the interests of an entire industry of stakeholders around a path of least regret, or to paying out incentives two years after quality metrics were reported. 

With access to the detailed care delivery data stored in their own applications and infrastructure across care settings, they can add, change, and delete metrics of all sorts to get the right level of insights to inform and make changes.  They can take calculated risks in more-controlled settings to see if they work and gage the impact on the whole delivery and payment system.  They can perceptibly link payment incentives to practitioner actions.  They can identify care delivery steps that don’t add value and remove them or add new steps to improve an outcome even if it would not have normally been reimbursed. 

In practicality, plenty of incredible practitioners don’t want to be employed by anyone but themselves, and high quality outcomes and low cost improvements are not at all the singular domain of IDNs.  However, to the extent that value-based reimbursement programs attempt to mimic the relationship that an IDN has with its employed providers, the hypothesis to be tested is whether we might accelerate achievement of our industry goals by chasing after large-scale nationwide quality measurement programs less and chasing integrated models like Kaiser more.

E. Todd Bennett