Organizing the U.S. Health Care Delivery System for High Performance

This report from The Commonwealth Fund Commission on a High Performance Health System examines fragmentation in our health care delivery system and offers policy recommendations to stimulate greater organization—established mechanisms for working across providers and care settings. Fragmentation fosters frustrating and dangerous patient experiences, especially for patients obtaining care from multiple providers in a variety of settings. It also leads to waste and duplication, hindering providers’ ability to deliver high-quality, efficient care. Moreover, our fragmented system rewards high-cost, intensive medical intervention over higher-value primary care, including preventive medicine and the management of chronic illness. The solutions are complex and will require new financial incentives, changes to the regulatory, professional, and educational environments, and support for new infrastructure. But as a nation, we can no longer tolerate the status quo of poor health system performance. Greater organization is a critical step on the path to higher performance. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff, or of The Commonwealth Fund Commission on a High Performance Health System or its members. This and other Fund publications are available online at www.commonwealthfund.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1155. iii cOntentS List of Exhibits iv Preface v About the Authors vi Acknowledgments viii Executive Summary ix I. Background 1 II. How Do We Want Health Care to Be Delivered? 3 III. Is It Achievable? 8 Iv. What Do We Know About “Organization”? 16 v. Trends in Physician Organization 18 vI. How Will We Get the Care We Want? 20 vII. Policy Recommendations 29 vIII. Conclusion 31 Notes 33

[1]  A. Kramer,et al.  Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention , 2004, Journal of the American Geriatrics Society.

[2]  Mark T Hegel,et al.  Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. , 2002, JAMA.

[3]  Stephen M Shortell,et al.  The impact of health plan delivery system organization on clinical quality and patient satisfaction. , 2006, Health Services Research.

[4]  T. Bodenheimer.  Primary care--will it survive? , 2006, The New England journal of medicine.

[5]  K. Grumbach,et al.  Does having more physicians lead to better health system performance? , 2008, JAMA.

[6]  B. Starfield,et al.  Contribution of primary care to health systems and health. , 2005, The Milbank quarterly.

[7]  Hoangmai H Pham,et al.  Delivery of preventive services to older adults by primary care physicians. , 2005, JAMA.

[8]  Sowmya R. Rao,et al.  Electronic health records in ambulatory care--a national survey of physicians. , 2008, The New England journal of medicine.

[9]  C. Schoen,et al.  Image and reality: managed-care experiences by type of plan. , 1996, Bulletin of the New York Academy of Medicine.

[10]  I. Motola,et al.  Patient Satisfaction with Different Interpreting Methods: A Randomized Controlled Trial , 2007, Journal of General Internal Medicine.

[11]  K. Davis,et al.  Closing the Divide: How Medical Homes Promote Equity in Health Care—Results from the Commonwealth Fund 2006 Health Care Quality Survey , 2007 .

[12]  L. Baker,et al.  Physician practice size and variations in treatments and outcomes: evidence from Medicare patients with AMI. , 2007, Health affairs.

[13]  J. Weiner,et al.  Prepaid group practice staffing and U.S. physician supply: lessons for workforce policy. , 2004, Health affairs.

[14]  Ateev Mehrotra,et al.  Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations? , 2006, Annals of Internal Medicine.

[15]  Joy M Grossman,et al.  Physicians moving to mid-sized, single-specialty practices. , 2007, Tracking report.

[16]  Chi-Hong Tseng,et al.  The Impact of Medical Interpretation Method on Time and Errors , 2007, Journal of General Internal Medicine.

[17]  Robert H. Miller,et al.  The Santa Barbara County Care Data Exchange: what happened? , 2007, Health affairs.

[18]  Francis J Crosson,et al.  The delivery system matters. , 2005, Health affairs.

[19]  B. Druss,et al.  Chronic illness and plan satisfaction under managed care. , 2000, Health affairs.

[20]  Ming-Yu Fan,et al.  Long-term cost effects of collaborative care for late-life depression. , 2008, The American journal of managed care.

[21]  C. Schoen,et al.  Public Views on U.S. Health System Organization: A Call for New Directions , 2008 .

[22]  Physician Leadership "Group Responsibility" as Key to Accountability in Medicine. , 2004, The Permanente journal.

[23]  S. Schoenbaum.  Implementation of preventive services in an HMO practice , 1990, Journal of general internal medicine.

[24]  Stephen C Schoenbaum,et al.  Measure, learn, and improve: physicians' involvement in quality improvement. , 2005, Health affairs.

[25]  M. Naylor.  Transitional Care: A Critical Dimension of the Home Healthcare Quality Agenda , 2006, Journal for healthcare quality : official publication of the National Association for Healthcare Quality.

[26]  M. Leavitt,et al.  Department of Health and Human Services , 2007, Disaster Medicine and Public Health Preparedness.

[27]  J. Selby,et al.  Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. , 1999, Journal of the American Medical Association (JAMA).

[28]  Janice A Singer,et al.  Does Affiliation of Physician Groups with One Another Produce Higher Quality Primary Care? , 2007, Journal of General Internal Medicine.

[29]  K. Davis,et al.  A PATIENT-CENTERED HEALTH SYSTEM , 2006 .

[30]  K. Davis,et al.  Obtaining greater value from health care: the roles of the U.S. government. , 2003, Health affairs.

[31]  J. B. Sterns.  Quality, efficiency, and organizational structure. , 2007, Journal of Health Care Finance.

[32]  M. Wakefield,et al.  The North Dakota Experience: Achieving High-Performance Health Care Through Rural Innovation and Cooperation , 2008 .

[33]  R. Feachem,et al.  Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente. , 2002, BMJ.

[34]  Paul B Ginsburg,et al.  Hospital-physicians relations: cooperation, competition, or separation? , 2006, Health affairs.

[35]  E. Keeler,et al.  Costs and benefits of health information technology. , 2006, Evidence report/technology assessment.

[36]  Kevin Grumbach,et al.  Physician organization and care management in California: from cottage to Kaiser. , 2004, Health affairs.

[37]  Jeffrey Johnson,et al.  The economic effect of implementing an EMR in an outpatient clinical setting. , 2004, Journal of healthcare information management : JHIM.

[38]  T. Meehan,et al.  Association between maintenance of certification examination scores and quality of care for medicare beneficiaries. , 2008, Archives of internal medicine.

[39]  Maureen Bisognano,et al.  THE COMMONWEALTH FUND Commission on a High Performance Health System , 2005 .

[40]  S. Shortell,et al.  Health promotion in physician organizations: results from a national study. , 2004, American journal of preventive medicine.

[41]  P. Shekelle,et al.  Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care , 2006, Annals of Internal Medicine.

[42]  Hoangmai H Pham,et al.  Unhealthy trends: the future of physician services. , 2007, Health affairs.