HEALTH CARE thoughts: Integration Speeds Forward
by Tom aka Rusty Rustbelt
HEALTH CARE thoughts: Integration Speeds Forward
Among those who ponder the operational aspects of health care reform, there is strong sentiment for more use of Integrated Delivery Systems (IDS) in delivering health care.
This is hardly a new concept, but it may well be the concept of the future.
My focus is largely on physician integration although there are other aspects, but the docs are the really big issue, as they drive admissions and order testing.
The first big IDS wave occurred in the early to mid-90s, as physicians and hospitals tried various medical service organization (MSO) models; essentially the hospital owned the physician practices. Many of these deals were disasters, some worked, some evolved into something that worked.
The idea is that if a central entity (an insurer, a hospital, or a hospital network) owns and coordinates services there will better care coordination and cost savings.
The successful integrations so far have largely focused on family practice, internal medicine and ob-gyn (the OBs assistance with malpractice premiums and 24/7 coverage issues).
An interesting change is surfacing, the acceptance of specialists and surgeons into IDS models. Historically there has been a great deal of friction between these docs and the hospitals.
Why the change? Fear of dire economic consequences of staying in a traditional group practice model. Preliminary numbers from the 6/30/2010 residency class is that for the first time, a majority may opt for IDS employment rather than group practice. There are also reports that young docs are more concerned with life balance issues than previous generations.
So, any problems?
Hospitals are notoriously bad at managing physician practices, physician contracts must be structured carefully, physician productivity sometimes drops off with a steady paycheck, and the process of merging practices and/or converting ownership is a great deal of complex work at no small cost. Also, making this work in rural areas is tough.
Biggest question, will IDS on a large scale really cut costs? Or just reshuffle the deck chairs?
Tom aka Rusty Rustbelt
Tom–My cardiologist used to be a partner in a local cardiology group practice. My guy and one other specialize in angioplasty procedures. They also want to become certified in open heart. Apparently that’s a big deal because you have to go to Tallahassee otherwise and a lot of patients can’t hack the travel involved. Big shop, five cardiologists, lots of hardware, staff had all LNP’s and three or four full-time clerks handling billing/insurance. Now, he’s still a member of the group practice, but also receives a salary from the local hospital/medical center. It’s got various clinics–out patient surgery, an imaging center with a MRI and multiple CAT machines, womens’ health center, big lab, and the usual ER/OR suites.
So, I see him in his shop, the practice bills for stress tests, and lab work goes to the hospital. These people consult extensively with local group practices and routinely share reports with other specialists and internists. Don’t know if it saves them any money, but they’re still in business and seem to have thriving practices. Meanwhile, the hospital is adding another wing. Seems to be mutually profitable so far if construction in a recession is any indication. Nancy O.
The big five hospitals (Mass General, Beth Isreal Deaconess, the Brigham and Women’s, Boston Medical Center, Tufts) http://www.bostonmagazine.com/articles/top_doctors_2009_bostons_top_hospitals/
have instituted IDS three years ago. Effective records if you stay in the large system, but records are not shared via computer link with the smaller hospitals. Fast access…yes. Cost effective? We shall see.
I have no data yet for western MA integration, which is rural enough to study.
You say primary care physicians were the first to go into IDS arrangements. In the Boston area, as I’m sure you know, there’s a big shortage of primary care physicians. People often go without, because there aren’t enough open patient slots. The newspaper stories say that people don’t choose primary care as a specialty because there is not enough money, and the hours are too demanding. These are both, I would guess, symptoms of a small number of colluding employers holding salaries down to save costs. Is there any connection between IDSs for primary care physicians and this shortage? I don’t know the answer, and there may be more to it.
Does an IDS differ in any really significant way from the HMO model? If it doesn’t, isn’t it likely that most of the hypothetical savings were incorporated into normal practice one way or another a couple of decades ago either by HMOs or by organizations trying to compete with HMOs?
Bill – great question.
In fact, the IDS arrangement tends to give docs stable incomes and eliminates the worry of funding office overhead. Also tends to allow hospitalists to cover hospital patients, which cuts down on the 14 hour days.
The shortage of primary care physicians has been caused by long hours, high expenses, smaller take home pay and unrelenting pressure of 24/7 coverage by the group.
There two major HMO models, HMO as provider and insurer, and HMO as insurer and coordinator. The second dominates.
IDSs tend to pull the strengths of the HMO models and tries to avoid the weaknesses.
Some IDS have an insurance subsidiary, other serve as negotiator with multiple insurers, and others do both roles.
At one point here it was impossible to get in to see your Primary Care physician without waiting months for appointments. Anyone who needed to see a doctor urgently went to Urgent Care and saw whichever doctor was ‘up next’. THEY never know if they were looking at a hypochondriac or a stoic, or if there were underlying medical conditions, allergies, etc, and didn’t have time to go back into the records and check because it was so busy. Not much point in a PC physician if you never see them when you’re sick; defeats the whole purpose of having physicians who know their patients.
Then they switched the appointment model, holding some appointments for each PC physician open until that morning. People could call in the morning and get an appointment that day when they needed to. Regular checkups were still scheduled further ahead, and Urgent Care was open later, on weekends, and to cover patients whose doctors were out that day.
That works out MUCH better. Probably saves some money too, since the physicians know better who needs reassuring, who needs tests, and who needs to be admitted STAT.