Thursday, May 28, 2009

Time to Speak the Unspeakable

It is time to undertake the consolidation of the professional and institutional components of health care.

I was reminded of this while perusing a recently issued supplement to the journal Health Affairs entitled Value in Health Care. Eleven articles were included

As I skimmed through the material, I was struck by the frequent use of code words that implied such consolidation. Examples include “system fragmentation,” “clinical integration,” “bundled payments,” “accountable care entity,” “accountable care organization,” and “physician-hospital integration.”

Only one author, Frances J. Crosson of Kaiser Permanente, was bold enough to address the issue head-on, saying that “Integration must occur at the clinical, operational, financial, and cultural levels….”

I would add that the result should be a single corporate entity headed by unitary management and governance that can be held accountable for the cost and quality of the care it provides.

There are a number of such entities now and so there is no shortage of models or precedent. The Mayo Clinic, Cleveland Clinic, and Henry Ford Hospital are examples. Even Myrtue Medical Center in my home town of Harlan, Iowa is so organized.

Creating these entities will not, by itself, achieve reform. Those that exist are generally considered to be among the better providers, but they do not stand out in any spectacular way. Although they are positioned to be accountable, our society has not, generally speaking, held them so and they have tended to follow traditional patterns of providing care.

To achieve real reform, other measures, like getting rid of fee-for-service, must also be implemented. But a number of them depend for full effectiveness on consolidating the provider system. Also, we need to be developing a cadre of leaders who know how to run such organizations.

And so we ought to get on with it and the first step is to agree publicly that it needs to be done, even if that requires speaking what up to now has been the unspeakable.

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