Clinical Integration: Lessons from Dean Clinic

By Craig Samitt, MD, president and CEO, Dean Clinic

Dean Clinic has been described as a present-day Accountable Care Organization (ACO) and a model of clinical integration. We’ve also been called a “structurally integrated organization,” an “economically integrated organization,” and even a “technologically integrated organization.” We are admittedly all of these things because we chose to pursue “better care at a lower cost” — the value path — long before the ACA was passed. But there are even more important types of integration than these to succeed as a high-performing Accountable Care Organization, as we have learned:

Lesson 1: Shared Accountability Is Far More Important than Structural Integration

One of the common misconceptions about an organization’s ability to succeed in accountable care is the belief that vertical and structural integration is critical to achieve synergy. The Dean/SSM Healthcare of Wisconsin partnership illustrates that this is not necessarily the case. These two separate corporations have worked shoulder-to-shoulder for over nearly 100 years with a common purpose and shared vision for excellence and value-based care — a virtually-integrated system from a structural standpoint. While we have, in recent years, become more structurally integrated via joint-ventures, these forms of partnership have not nearly been as important as the alignment of our value-based cultures. We have a common vision toward value, even at a time when financial incentives encouraged us to pursue a volume-based path. Together, we chose not to divide a fixed and shrinking revenue pie between us and instead have found ways to share gains, risks, higher-margin services, and investments to improve our performance.

There are three accelerating and competing structural integration verticals emerging today, each aimed at dominating markets: health plans that are seeking to acquire delivery systems, hospitals that are moving to employ doctors, and physicians that are embracing full-risk and vending downstream services to hospitals and others. In our view, the ability to become a high-performing accountable care organization is less about which of these models is preferred or even where their journey began, but rather more about achieving a state that represents a “team of equals.” In our organization, each effort to improve patient satisfaction scores, raise ambulatory or core hospital quality measures, or improve efficiency involved the attention and expertise of physicians, hospitals and health plans in partnership. In short, it’s the alignment over a common set of goals, the singular focus on a common set of metrics, and the power of shared accountability that is far more important than structural integration in driving our system’s performance.

Lesson 2: Aligned Incentives Are Far More Important than Economic Integration

What motivated Dean’s journey down the value-based path was our recognition at one point in our history that we had a “foot on a dock” (volume-based revenues via fee-for-service payers) and a “foot in a canoe” (capitated payments via our owned health plan) — and the recognition that the dock was burning and the canoe was leaking. Ultimately, we chose to pursue the value path and deliver better care at a lower cost in earnest for all our patients, regardless of payer.  Many believe that we’ve had the freedom to pursue value because we’ve owned our own health plan (whereas others are starting their journey standing on a burning dock with no canoe in sight). While there is some truth to that premise, we would argue that Dean’s transformation to value had more to do with the fact that the bearing of risk catalyzed a paradigm shift in our approach to care and a transformation of our operations. If it were not for our economic integration, we would not have had the toolkit of processes, technologies, strategies, and innovations to maximize value-based care that we have today.  However, at the end of the day, it’s the toolkit along with aligned incentives (regardless of payer) that is far more important than the economic integration.

Fast-forward to present day and we find that we have stepped off the burning dock and have patched the canoe. While our health plan is strong and growing, we have pursued gain-sharing and risk-sharing payment methodologies with most of our other payers, including Medicare via the Shared Savings Program (MSSP). In our view, the beauty of the Medicare MSSP, Pioneer, and Bundled Payments programs is that they offer health systems the opportunity to step into their own canoes.  Ultimately, our desired end-state is to not only be clinically accountable, but to be economically accountable for all our patients, and to have most, if not all, of our incentives aligned toward value over volume.  This alignment of incentives is not only important in the payer-provider relationship, but is even more important between a provider organization and its doctors. We’ve learned quite clearly that you can’t pay doctors for volume when your organization is paid for value.  ACOs must also learn how to re-design physician compensation models and align incentives from the very top to the very front line of our organizations.

Lesson 3: The Ability to Compile, Compare, Analyze, and Report Information Is as Important as Technological Integration

Along with shared accountability and alignment of incentives, two of the most crucial drivers of the transformation at Dean have been our willingness to embrace the use of technology and to use data effectively to drive decisions and motivate change. Implementation of an electronic health record is essential but not sufficient to become a high-performing health system. Likewise, meaningful use of EHRs is essential but not sufficient to be “accountable” in the future. We would argue that our greatest organizational success will only be achieved when we “optimally use” our technologies and integrate them into the very fabric of our care-delivery model. ACOs must make sure that we are using EHRs to their fullest potential to influence improvement in quality and maximize preventive screenings, service enhancements, patient adherence or cost reductions.

But even that will not be enough to be sufficiently high-performing in the world of accountable care.  From our vantage point, the ability to compile, compare, analyze, and report information is the most important component of the world of integrated health information technology and data. As Dean has evolved from a system of volume-based care to population-based care, we have vigilantly benchmarked our performance against other organizations, shared un-blinded comparative data with clinicians regarding service, quality and cost, and transparently reported data to our markets as a means of growing our practices and competing in the world of health insurance exchanges. We’ve also developed a comprehensive “big data” data-warehouse and analytics shop so that we can predicatively model clinical information, identify areas of quality/safety/cost concerns, and assess variations in practice patterns. While we struggle every day with the accuracy, transparency, format, and availability of data today, we’ve invested heavily in data creation, analysis, reporting and modeling at Dean because it is quite clear to us that data will be king in the world of value.

The original version of this article was published by Accountable Care News, December, 2012.

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