The only way to track these issues is to have a prospective database – a total joint registry – of all implanted devices. We have done that within KP and have the largest total joint registry in the United States. There are few other databases to compare ours to in the US. Ideally a government funded and mandated implant registry would provide some information necessary to track complications, and outcomes. That doesn’t exist presently – it should.

From my perspective as a surgeon the administrative databases used in the US in general can track only about 25% of what’s important in looking at outcomes from a patient’s perspective. Risk adjusting also means that the data has to be aggregated at a high level to be accurate – that means that individual surgeon data is relatively meaningless. I have looked at this many, many times and know that without sufficient volume you cannot make judgements about quality. The other part of the equation is that the team you are working with makes all the difference in the world. We have discovered that having a total joint “team” in the operating can shave 40 minutes off operative time, and provide better quality care. Yet not all surgeons have access to such teams. The majority of total hip replacements done on Medicare patients in the US are done by surgeons who do fewer than 25 hip replacements per year – and due to the low volume these surgeons won’t generally have access to these teams.

So, until we have a national total joint registry, and are therefore able to better measure outcomes on a national scale, and have clearly definable cost per procedure it will be difficult to have competition on episode of care criteria for total joint replacement in a rational market based manner.

Perhaps more detailed patient data from Kaiser’s new EMR system will make this possible. But better data does not eliminate the complexity problems noted by a number of HA blog participants. And even assuming that Kaiser’s EMR system is a semi-fixed, sunk cost – there will be additional variable costs associated with developing an episode of care-based management/reporting system using these data. Some of these costs will be financial and others will be organizational, stemming from cultural barriers to implementation. While the benefits to Kaiser of managing by “episodes of care” may be recognized, this approach will be pursued only if Kaiser decision-makers (health plan and PMG execs) decide that the benefits exceed the costs of changing from the status quo.

My recent experiences as a Kaiser member suggest that this is unlikely to happen. The major reason is not so much the financial cost. Kaiser is currently spending multi-billions of dollars on IT hardware, software and most of all, consultants, to implement a new EMR system expected to differentiate it from the competition for the foreseeable future. My doubts are based on my knowledge of Kaiser’s organizational culture, and in particular, the PMGs’ attitudes about (i.e., resistance to) sharing MD-specific info with others in Kaiser, even other MDs and esp.with members.

In trying to understand the prospects for large, well-integrated medical groups to adopt an “episode of care” approach to management, Jamie points out what seem to be obvious benefits: “Service line focus and performance-based payment perhaps can make large organizations a bit more transparent and a bit more manageable to those within them, physicians and well as patients?” Although more transparency sounds great from both management and customer/patient perspectives, greater transparency re PMG MDs’ comparative performance is not something that Kaiser seems ready to promote anytime soon.

To illustrate, let me share a personal experience. A couple of years ago, due to family history of colon cancer, it was recommended that I have a colonoscopy. With my public health and research background, my first reaction was to figure out if the risks (potential costs) of this screening test outweighed the benefits for me, personally. I quickly learned that, aside from anesthesia, the main risk is from perforation and this happens in general in 1 in 1,000 cases. Perforation can be very serious; morbidity can be severe and there is a 5% mortality rate. The literature I consulted indicated one way for patients to reduce risk was to find a GI specialist who was very skilled and experienced at this procedure.

Ideally, it would be best to compare MDs’ actual complication rates, but given lack of data, I realized that using procedure volume as a proxy was the best I could do. As a Southern California member, I am able to get my care from any Kaiser location in this part of the state. At that time, there were approximately 25 GI specialists who did this procedure and so before I committed to any one of them, I asked for the following comparative information: 1) colonoscopy complication rates over the past 2 years, if it could be appropriately risk adjusted; and, if not available; 2) colonoscopy volumes over the past 2 years. I think I also requested the number of years that each MD had been doing this procedure.

Kaiser’s response was extremely disappointing. They (Member Service Dept and the Southern California Permanente Medical Group – SCPMG) initially ignored my requests for this information for at least 3-4 months. I suspect they were hoping that if they delayed long enough I would just give up and leave them alone. While I eventually got a referral to an MD who I expect fit my criteria for high quality based on other evidence I had, I never got any comparative procedure volume statistics. I believe I was finally told that the medical group did not keep these statistics in any form that could be used to easily generate a report. But my impression is that they felt it inappropriate for members to see to see this information that could reveal any variation among SCPMG MDs.

Transparency is the ideal in any market situation, but in health care this runs smack up against the culture of medicine, where secrecy is clearly the norm. Confidentiality is not universally bad. It is probably necessary for many aspects of peer review to function effectively. For example, surgical morbidity and mortality conferences allow MDs to at least acknowledge and deal with problems that have occurred, without the immediate threat of assigning blame. But if this attitude about the value of secrecy limits release of ANY comparative info about MDs, patients will never be able to make informed choice of a provider. Based on my recent experiences, Kaiser MDs are no different from any others in this respect.

But of course I could be wrong about the PMGs’ willingness to release this info to members in the future. I had been hopeful that things would improve when George Halvorson became CEO of Kaiser, since his public statements while at HealthPartners were very supportive of consumers’ needs for MD-level information. Re Kaiser’s future plans, I would be very interested to get feedback from Dr. Barber, other PMG MDs and/or any others associated with Kaiser. Perhaps my experience was unique to SCPMG, so a specific question for Dr. Barber: Can a Northern California Kaiser member who is a prospective total hip replacement patient get comparative information on MD-specific complication rates for this procedure or at least procedure volume data?

I certainly can understand the concern about validity/reliability of outcome measures such as MD-specific complication rates until we feel confident about the accuracy of risk adjustment. But I’m still puzzled and quite disappointed that procedure volume, esp. for something as common as colonoscopy, was not available. I do not see why Kaiser members who request it can’t have access to this level of data even today. And if Kaiser is not willing to release MD-specific procedure volume data, I don’t see much hope that Kaiser members will ever get greater transparency re episodes of care.

To rGivens I have to say that the complexity of a service such as renal transplant demands extensive scrutiny and understanding. Certainly in most traditional measures of quality the renal transplant program was immensely succesful – low mortality, very high kidney survival rates, few complications. It is what wasn’t measured that was the problem – access to the program. In every area you will see examples of complexity tripping up outstanding providers. In England a one year wait for a total hip is routine, as is a two week hospital stay (has improved over the last few years). They care deeply about their patients, and their OR efficiency is remarkable. But they didn’t routinely measure access, or service, or LOS and didn’t understand the complexity of the systems they are dealing with. The interactions and communication of the doctors, adminstrators, physical therapists, nurses, discharge planners, OR techs, anesthesiologists, consulting physicians, and of course the most important ,the patient are critical to success. An integrated system provides the best integration and communication and the plan by Porter ignores that reality.

Dr. Robinson’s answer is that traditional medicine has tried episodes of care before, and it wasn’t succesful – I personally was involved in an attempt to sell total hip services to insurers in Boston in 1986, and other episodes of care type of provision of services were tried throughout the 1990’s without great success. The best success has come from specialty hospitals – cardiac and orthopedic where synergy and common goals have led to top quality and low cost. This has been at the expense of the community hospital, and perhaps at the expense of decreased access to emergency services. The complexity and lack of clear quality parameters means that a free market becomes less likely to be succesful as one moves from aggregation at the plan or group level to a more specific episode of care.

The success of Professor Herzlinger’s writings is evident in the performance of a myriad of focus factories that have delivered both convenience and value to the consumer, from the players in the dialysis industry focused on the facility portion, such as Da Vita, to the recent interest in the “MinuteClinic” model, focusing on a limited number of diagnoses and treatments that are based on clear guidelines and protocols. The significance of activist consumers seeking to play a more central role in managing their health care will, if anything, accelerate with the new generation of transparency tools relating to cost and quality that are coming out of entrepreneurial companies seeking to ride this trend.

As one individual noted above, “episodic-based pricing is a great idea in theory;” however I would not hold by breath waiting for providers to come together to embrace the concept.

We don’t see episode of care pricing and service line based organizations because consumers are not demanding it. Probably most don’t understand that this way of delivering care might be better (from a quality and/or cost perspective) than how it’s delivered now. There may be a few exceptions, but benefits of this approach have simply not become obvious to enough patients to push the market to a critical mass. And if consumers are not clamoring for this approach, why would health care providers (very conservative as a group based on my past experience working for the California Medical Assn) bother with the cost/effort of changing their traditional mode of operation? In addition to general increase in costs/hassles to change this well-established model of care, I’m of the opinion that most providers (unless they know for sure how, relative to the competition, superlative their care is, and feel this is unrecognized) DO NOT want consumers/patients to have more transparency about cost and quality. The providers in fact like the murkiness of the current price/quality info environment just fine as it is.

Implications? 1) until patients (large numbers of real patients and not just policy wonks) understand that care could be better if organized as suggested by Porter/Teisberg, they will not demand this approach and no provider will have any incentive to make related organizational and info changes; 2) even if patients eventually get educated, begin to demand such changes in medical care organization AND are willing to pay more to cover related system transition costs, MDs are likely to resist. Making more information available will only help those unrecognized, above-average performers – but hurt those who are average or below (the majority). Not exactly the same situation, but this is what Leapfrog discovered when it tried to get major hospitals in the St. Louis Area to participate in its IT implementation and quality survey. As someone at BJC apparently told Louise Probst of the Gateway Purchasing Group (and not to for attribution!), providing info can only be expected to reduce local hospitals’ status in the eyes of consumers. Given these two barriers, I think that evolution of the health care marketplace in the direction that Porter/Teisberg favor is highly unlikely.

1. Is healthcare patient driven or provider driven?

It has been driven by the powerful constituents, which have lobbyists able to influence policy. These influencers include the pharmaceutical companies, medical device manufacturers, insurers, and healthcare providers. Unfortunately, patients/consumers and researchers have lacked much influence. Some argue that employers as have the power to make a difference (see CPHR ). While there’s recent movement toward patient-driven systems, there is a long way to go.

2. How do we find an equilibrium amongst the healthcare dynamics?

Through consumer-centered, universal healthcare, transparency of the price and quality of care delivery and healthcare plans, incentives tied to accountability and performance, value-based competition, and increased support for good collaborative research would be very helpful.

3. Is there any particular standard or certification that can prove healthcare is properly regulated?

There are professional licenses, the FDA, some established standards of care, and the threat of malpractice suits, and consumer watchdog and advocacy groups. But there are weakness in post-market drug and device surveillance; in the oversight by professional organizations; in the generation, evolution, dissemination and use of evidence-based guidelines; in power and influence consumer groups; and in the collection and analysis of clinical outcomes data.

I agree that global thinking – seeing the “big picture” and understanding how all the parts of our healthcare system interact – is essential for making decisions about meaningful reform. Empowering and enabling patients/consumers, researchers/scientists, and employers to help influence the system’s transformation would balance the power. Adopting a non-zero sum economic model is also an important aspect of any win-win strategy.