Encouraging the Formation of Integrated Systems
Executive Summary

Forum III

March 5-7, 2007
Santa Monica, Calif.
Slides of final rankings of principles by participants (PDF)
AMGA workshop principles (PDF)
Agenda

Mayo Clinic Health Policy Center convened 24 leaders from across the country in Santa Monica, Calif., to discuss how to improve the integration of health care. The meeting was co-hosted by the RAND Corporation. The session was a response to one of the major themes which emerged from the 2006 symposium — improving the coordination of care, particularly care for patients with chronic illness.

To set the stage, Robert Smoldt of Mayo Clinic presented an example of a Mayo Clinic liver transplant patient who, in the course of a 5-day hospitalization, interacted with 75 different caregivers over 11 different shifts. He said the opportunity for problems with the number of handoffs involved in patient care is what makes coordination such an important topic.

Elizabeth McGlynn, Ph.D., RAND Corporation, defined clinical integration as coordinating patient care services "across people, functions, activities, sites and time." The goal of coordination is to improve quality, reduce costs and, thereby, increase value.

Some of the group argued for a broad view of integration, as a partnership between patients and a broad range of providers in the pursuit of health over a lifetime. "What's really driving health outcomes," said one physician participant, "are decisions people make when they're not in our presence: Do they take their pills; do they exercise; what do they eat; how do they handle their anxiety?"

In the end, the group (which included providers, academics, policy experts and consumer advocates) agreed on four major principles to better integrate care:

Patients must be at the center of the care system and have the right to coordinated quality care; integrated practice behavior (cooperation) is essential.
Participants agreed that our current "system" is provider-centered, not patient-centered. ("Health care is the only industry that has institutionalized the waiting room," noted one participant.) What is most needed is a system that provides patients with a single point of coordination and interpretation.

Participants also agreed that it is important to foster an attitude of interdependence rather than independence. They agreed on the need for incentives to encourage care givers to coordinate care; for example, better reimbursement for spending time with patients.

Group members also emphasized the need to conduct and broadly disseminate more research about the structures, processes and leadership that produce the best integrated care.

From left, Alain Enthoven, Ph.D. and Ian Morrison, Ph.D.

The goal of the delivery system is to improve the health of the population.
Participants agreed that many changes are needed to realign the health system toward improving health rather than treating disease. One important step is to encourage measurement and reporting of quality performance at the organization level. Another is to create care models that allow electronic data and information to be shared.

Participants felt that a "portfolio of incentives" should be developed to help encourage health professionals to work together. These could include financial, outcomes reporting, electronic medical records and professional pride ("Doctors don't like to see a one-star rating after their organization's name in the newspaper," said Randall Linton, M.D., Luther
Midelfort).

There was agreement that transparency and dissemination of outcomes data would be strong drivers of integration.

Another high priority was relief from anti-trust laws that discourage independent entities from joining forces to improve integration.

The payment system must be changed to achieve substantive health care reform.
Money drives the system, and participants felt that Medicare and other payers' purchasing power should be harnessed to create a payment system that rewards value, coordinated care and good outcomes, and that penalizes uncoordinated care.

The group recommended that, where possible, care should be paid for on a prospective, risk-adjusted basis. This would encourage investment by health systems to keep people well. "Admission into the hospital is a failure of the system," said Denis Cortese, M.D., Mayo Clinic.

Patients should have complete and accurate information to make informed decisions about their care, should have a personal relationship with a care provider, and be involved in the health care system.

Randall Linton, M.D. and Sylvia Drew Ivie, J.D.

Participants agreed that patients should have:

• Appropriate, quality, evidence-based care when they need it.
• Ownership and access to their personal health information from birth to death.

They group supported a unified patient identifier to promote portability of information. There was also strong agreement that integrated systems should extend to the local level and that providers at all levels should work together to improve health.

Next Steps

The recommendations from all the Policy Forums will be reviewed, discussed and prioritized at the Mayo Clinic Health Policy Center's 2nd National Symposium on Health Care Reform in March 2008. The ultimate goal is to engage a cross-section of stakeholders and build a public mandate for change based upon common principles.

Divergence Points

Though there is increasing evidence of higher quality provided by integrated systems, others suggested the need to demonstrate conclusively through further research that "the delivery system matters." It was also noted that integrated practice models are scarce in many parts of the country.

Not everyone thought that integration by itself would cure the ills of the medical system. It was seen as perhaps the most promising way to achieve better health care, but not the only way.