Category Archives: Medical Home

Crossover Health: Welcome to Next Generation Health Care!

Crossover Health Launches New Model of Primary Care in South Orange County
Innovative membership service delivers Urgent, Primary, and Online Care

Aliso Viejo, CA (PRWEB) October 1, 2010

Crossover Health Medical Group announced today the launch of their flagship membership-based, primary care practice in Aliso Viejo, California. The new clinic will offer urgent, primary, and online care services directly to individual members, families, and employer groups. Membership based health care is a new health care finance and delivery innovation that has gained widespread popularity as the cost of health insurance and ongoing service deficiencies have plagued the current health care delivery system. The Crossover membership model decouples health care from health insurance, and allows individuals and organizations to purchase primary care directly from health care providers who offer increased access, enhanced services, and an exceptional service experience.

“The membership-based practice model allows Crossover Health to fundamentally change the way health care is practiced, delivered, and experienced,” according to Chief Executive Officer Scott Shreeve, MD. “Crossover has been specifically designed to restore and enhance the patient-physician relationship, increase access and convenience, reduce the cost of health care, and deliver an unprecedented patient experience.” The membership fee pays for access to the technology enabled practice and wellness services, as well as affordable prices for office visits, specialty consultations, and ongoing health management followups. A health concierge is assigned to each member to assist in overseeing follow-ups, proactive health maintenance, and care coordination. Crossover also provides health advisory services to guide patients in financial decisions related to the management of their health.

Crossover Health introduces two key innovations to the membership model. First, Crossover members have direct access to their physician via Crossover’s unique online, anytime, from anywhere technology platform that includes options for email, text, and video chat consultations. Second, the technology also enables a direct financial, administrative, and clinical relationship between the patient and their personal physician and the extended Crossover care team of medical specialists, diagnostic testing centers, and other licensed professionals. This inherent connectivity enables the creation of the Crossover Health Network™, a network of specialist providers who commit to deliver to a specific service level, make their prices transparent to members, and communicate on a common platform. The result is a simple, efficient, and affordable care experience.

“Many people, including employers, are surprised to find out how affordable exceptional health care can be when purchased directly from the physician,” said Chief Medical Officer Richard Patragnoni, MD. “Members can typically save a significant amount of money while enjoying a broader range and higher quality of personalized service to meet individual, family, or corporate health needs.” Crossover offers a variety of individual and corporate memberships that provide essential primary and preventive care services as well as targeted wellness programs like medical weight loss, executive health programs, health portfolio management, and virtual clinics.

Crossover Health memberships appeal to individuals looking to establish a personal relationship with a physician, families whose care requires a higher service level, and busy professionals who need flexible access to their physician. Membership care is particularly attractive to employers facing annual double digit health care cost increases. Employers using this model have consistently shown significant reduction in inappropriate utilization, dramatic improvements in satisfaction, and cost savings of up to 50% when bundled with lower premium insurance plans. Crossover Health is currently accepting new members throughout the Orange County area.



Filed under Change Agents, Crossover, Design, Direct Practice, Entrepreneurship, Innovation, Launch, Medical Home, Membership, Primary Care, Quality, Value

A Dream Fulfilled – Crossover Health to Open Flagship Store!

Dear Friends and Family,

As you know, we are thrilled to announce the opening of our flagship Crossover Health store in Aliso Viejo, CA later this Saturday. We are hosting a Grand Opening Reception on September 25, 2010 from 5:30 to 7:30 PM at 26831 Aliso Creek Road, Suite 200. We look forward to celebrating with our friends, family, and colleagues who have helped to make this event possible. We look forward to seeing you there.

Crossover Health is a next generation health care organization that uses a membership based approach to fundamentally change the way health care is practiced, delivered, and experienced. Crossover has been specifically designed to restore and enhance the patient-physician relationship, reduce the cost of health care, increases access and convenience, and deliver an unprecedented patient experience. We look forward to sharing with you how we do this and how you can benefit from this new type of health care.

Be Direct. It is surprising how affordable, simple, and efficient health care can be when you purchase health care directly. Image used with permission from HelloHealth.

At the Open House we will showcasing our new store, demonstrating our technology platform, discussing our unique practice model, and highlighting the growing network of medical professionals, diagnostic facilities, and other referral partners who make up the Crossover Health Network™. Be one of the first to learn about and benefit from our urgent, primary, and online care services.

We look forward to welcoming you to this Saturday at the Grand Opening Reception!

1 Comment

Filed under Crossover, Innovation, Launch, Medical Home

CPT Codes-Why physicians always get screwed, thanks AMA

CPT Codes

  1. Set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology
  2. Established in 1978 to provide a standardized coding system for describing specific items and services provided in delivering health care.

Daniel Palestrant comes right back from his opening salvo of last week to continue his crusade against the AMA. In another hard hitting email blast sent out to his 100,000 physician community he lays out the case of how the CPT system, maintained and propagated by the AMA, actually holds physicians hostage to the insurance cycle of care. He also lays the groundwork for the new retail health care economy where CASH will be king, relationship with the provider will be DIRECT, and physicians and patients will once again re-establish a relationship built on trust, advocacy, and professionalism.

This should be put in context with the recent announcement that Qliance just received $4M, Hello Health continues on an unprecendented media tear, and groups like Current Health and Crossover Health can emerge in this reality for American medicine. Whether or not we actually end up with health reform this year, you can be assured that Americans will want a separate system of “off the grid” providers.

July 8, 2009

Dear Dr. Shreeve,

In the healthcare debate it is rare that we find a single issue that all parties can agree is a big part of the problem.  Too much paperwork and complexity in the billing process is one of those few things.  Lately, EMRs have been lavished much of the attention and money; however, medical records are not the problem.  CPT codes are.

For most physicians, Current Procedure Terminology or CPT codes have become a defining aspect of how we must practice medicine.  They have become the “currency” of healthcare, mandating all manner of payments to physicians from the most complex surgical procedures to routine office visits.  In the process, the CPT coding system has turned into an incredibly complex system of codes, modifiers, and exceptions.  Add to that the RVU formulas, and it is no wonder that most physicians are drowning in paperwork.

Physicians feel the impact of this system in their day-to-day practice, especially on cash flow.  Not only do we have to maintain an extraordinary overhead of staff to submit, resubmit and document around CPT codes, the system robs the physician of any leverage we have with payors.  Once we have rendered care for our patients, we must submit (and often resubmit) forms to outside parties to get paid. Make no mistake, the more complex the system, the greater the opportunity payors have to delay and/or refuse payment to physicians, not to mention manipulate those reimbursements to their own advantage, as we have seen in the recent case led by the New York Attorney General against insurance companies.  Their profits grow at the expense of your cash flow.

The negative impact on physicians might be even greater when considering how handicapped physicians are in negotiating reimbursements for a given CPT code.  The current system allows payors to aggregate physician payment statistics, carefully playing one physician off another to negotiate down physician payments, while it is an anti-trust violation for physicians to compare data with one another, much less unionize.  It helps explain why physician compensation goes down every year while demand for those same services continues to explode .

As the national healthcare debate rages on, it is important to recognize that physicians are not the only victims of the CPT codes, the general public is too.  Beyond the massive administrative overhead (it is estimated that 20-50 cents of every healthcare dollar goes to administration), there is something worse, much worse.  The CPT system is privately owned.  Its use is strictly limited so that licensing fees can be obtained.  This has the unfortunate side effect of keeping the general public from doing easy comparisons of healthcare goods and services, also benefitting the insurance companies (who do not want those side by side comparisons because they promote competition and transparency).  There have been many attempts to break the CPT monopoly, most notably by Senator Lott in August of 2001.  Somehow they have always managed to remain in control.  Of course it’s a reliable revenue source.

Beyond offering a tremendous opportunity for improving our healthcare system, one has to wonder why this issue hasn’t been a topic of more focus.  With so much consensus around the excessive complexity and overhead in the billing process, this is completely baffling.  Dentists, lawyers, plumbers pretty much every professional in this country has avoided the fate physicians now face, allowing the market forces of supply and demand to create balance.  Only physicians have seen third parties come between them and their patients.

So who do CPT codes benefit? Well for starters, the AMA receives approximately $70 million in “licensing fees” from anyone who needs to use those codes.  Add to that insurance companies (who pay the AMA many of those millions) who can use the CPT coding system to further their own gains at the expense of the physicians, and it starts to make you realize why CPT codes have been so conveniently left out of the current debate.

So what’s the alternative?  Pretty simple.  Physicians have a service and people are willing to pay for it.  We are the single most critical part of the healthcare system.  We need to start acting like it.  We are at the dawn of a new era in the medical profession.  There is a New Business of Medicine upon us.  Sermo’s data shows that there is a trend towards alternative practice styles (fee for service being among the most prevalent) that is quickly turning mainstream.   To quote another Sermo member, “the new CPT: Cash Please, Thanks.”.  Leave the old CPT to the insurance companies.

The current CPT coding system represents a collusion of convenience between the business side of the AMA and the insurance companies…. at the expense of physicians and patients.  Perhaps most galling, thousands of physicians work on the CPT codes, for which they receive no compensation, while the AMA generates millions of dollars in revenue.  Clearly this presents a massive conflict of interest as the AMA is supposed to be advocating for physicians, yet it receives the majority of its revenues from the very same insurance companies that the rest of the physicians increasingly find themselves facing off against in the deepening healthcare debate.

As overwhelmed as we are with the offers from this community for financial contributions and your willingness to volunteer on behalf of this effort, for now we’d ask that you help us in mobilizing our colleagues in this effort. Remember:

Focus on the things that unite us, ignore the things that divide us. Concentrate on large numbers. Take a stand. Tie a knot.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc.


Filed under Direct Practice, Innovation, Irony, Medical Home, Value

The Geisinger Experience: Realizing The Health Value Vision

Realization (ə-lĭ-zā’shən)

  1. The act of realizing or the condition of being realized.
  2. The result of realizing.

Today, I am meeting with the X PRIZE Foundation at our 2nd Health Advisor Summit meeting in Washington, DC. We have gathered a small subset of health care thought leaders, innovators, providers, payors, patients, and employer groups to discuss the design of an incentivized competition for our health care system. It has been and continues to be fascinating work.

I have been privileged to talk to some of the luminaries within the health care field, individuals that I have read about for years (Weinstein, Nussbaum, Schwartz, Pardes, etc), but now have the privilege to interact with on a near daily basis.  One of those, Dr. Glenn Steele from Geisinger Health, has been particularly enjoyable to work with. I have been impressed with the incredible work they have done at Geisinger, not just their outcomes, but their thought process and the leadership behind making the required changes to achieve the results they have.   Glenn has actively participated in the X PRIZE design, and I have been impressed with his insight, his approach to problem solving, and what his team has accomplished to date.

They are the rubber hitting the road for the value driven health movement. Dr. Steele recently presented to Congress, and the entire body of his comments are included below because they are that good . . . and provide some insight into some of the transformative new deliver and new payment models that the X PRIZE hopes to catalyze. It is a bit long, but well worth your time (highlights are mine). For those who need to go right to the punchline, here it is:

The money quote: “We have improved outcomes and have reduced costs. This is because we have systematically researched how best to deliver care, hardwired the process steps into our electronic health record to prompt us on what best practices are, decreased unjustified variation, and taken financial risk to decrease related complications.”

Healthcare Reform – Changing Reimbursement That Reflects Value

April 1, 2009

Chairman Rangel, Ranking Member Camp, and members of the Committee,

Thank you for the invitation to testify at your hearing on healthcare reform and national system changes that can support quality and value in healthcare delivery. At Geisinger Health System, we serve a population that is poorer, older and sicker than the national averages. Most of our patients have multiple chronic diseases, such as diabetes, high blood pressure and lung disease. Our patients have difficulty navigating through a complex healthcare system. They need help and we have made a concerted effort to put into place electronic and other innovative methods that will provide them with the assistance to maximize their ability to get care.

At Geisinger, we hold ourselves to high standards of assuring quality outcomes in serving these patients. For example, if a patient is readmitted to a hospital after a procedure or an in-patient stay, we believe we have failed that patient. Consequently, we have committed significant resources and have worked aggressively to bring value to healthcare and eliminate failures by redesigning how we provide care. The innovations we have instituted at Geisinger that bundle payments for acute care procedures, enhance support for primary care physicians and their care teams, better manage chronic disease and the transitions of care for patients from caregiver to caregiver, have produced significant cost savings and improved quality. Admissions for our patients with multiple chronic diseases have been reduced by as much as 50% in community sites. I believe that what we have accomplished can be adopted nationally and will achieve similar cost savings while improving quality. This would result in significant positive consequences for large payors, particularly Medicare.


I am Glenn Steele, the President of the Geisinger Health System, an integrated healthcare organization located in central and northeast Pennsylvania. Before coming to Geisinger, I spent 20 years as a practicing cancer surgeon at several Harvard hospitals and served as a Chairman of the Department of Surgery at the New England Deaconess Hospital. I then became Vice President for Medical Affairs and Dean of the Division of Biological Sciences and the Pritzker School of Medicine at the University of Chicago. Consequently, I have firsthand experience with patients, their access (or lack of) to care, issues that affect physicians and other caregivers in providing adequate and timely care, and the difficulties in juggling medical education and research, while facing ongoing changes in healthcare reimbursement.

In 2001, I came to central Pennsylvania because Geisinger offered the potential as an integrated healthcare system of developing cutting-edge approaches to increasing efficiency, value, and quality in healthcare. In short, we could attempt to transform healthcare using both our healthcare insurance product, and our clinical delivery system working together to benefit our patients. We serve a population of 2.6 million located in central and northeastern Pennsylvania. And we have an electronic health record (EHR) that was implemented 14 years ago with now more than 3 million individual patient records. Geisinger has been named as “Most Wired” by Healthcare’s Most Wired magazine six times.

We have our own health care insurance product – Geisinger Health Plan – that has nearly 235,000 members, 35,000 Medicare beneficiaries, 18,000 empanelled physicians, 90 hospitals (not including our Geisinger hospitals) and spans 43 of Pennsylvania’s 67 counties. We also lead our area’s regional electronic health information sharing platform1, called the Keystone Health Information Exchange, with (currently) ten hospitals and approximately 700 private practices sharing valuable medical information. This secure, patient-approved sharing of information means that our doctors, and more than 1,500 non-Geisinger caregivers can access patient information 24/7 from anywhere – a remote two-doctor primary care office, a multispecialty clinic, an operating room, or at 3:00 am from home.

Our patients access their own electronic health record. They can see their lab results, radiology results, request prescription refills, and email their doctors, nurses, and staff with questions anytime. And, they schedule their own appointments on-line. Geisinger has a large number of elderly patients (many greater than 80 or 90 and more and more now exceeding 100 years of age). Most have multiple chronic diseases and have family living outside of our area who follow their parents’ care through the electronic record (with appropriate patient approval). Geisinger employs about 800 physicians who see patients in more than 50 clinical practice sites; 38 of which are primary care sites in local communities. As clinically appropriate, physicians in these clinical sites admit their patients to nearly 20 local community hospitals – ensuring that patients receive most of their care near where they live. Only if necessary, are Geisinger patients treated at one of our three specialty hospitals.

Geisinger’s innovation2  is intended to attack fundamental flaws in our country’s payment for and delivery of healthcare. The U.S. suffers from a variety of reimbursement and care delivery issues that do not produce good clinical outcome. There is wide and unjustified variation in care. Fragmentation of care is rampant; our “hand-offs’ (that is, transferring important medical and family information as patients are moved from one environment to another) are disjointed and most often result in patient care that is not coordinated and is confusing to the patient. We have a perverse method of payment – one that rewards units of work regardless of patient outcome.

At Geisinger, we invest in quality and pay accordingly. Doctors who have better clinical outcomes are rewarded (financially and by recognition) and we constantly measure our outcomes against our peers, both within Geisinger and nationally. Physician, staff and site incentives are built into our system. And we reward quality and value, not just numbers of patients seen or numbers of procedures performed.


A great paradox in U.S. healthcare is that we get paid for making more mistakes. For example (with few exceptions), if a patient develops a post-operative complication that might have been avoided by proper care, we often receive more reimbursement for that case than for a comparable case without a complication. This does not happen in other industries. Why are healthcare services an exception? Consequently we believe our care design should be based on best evidence. In 2006, we started tackling the perverse payment incentives noted above by redesigning how we provide elective cardiac surgical care – what is known as coronary artery bypass grafts (or CABG)3. CABG is an episodic acute event – an event with a determined time frame from diagnosis through rehabilitation and recovery (unlike chronic disease, which stays with you for life). Our cardiology service line reviewed the American Heart Association and the American College of Cardiology guidelines for cardiac surgery and translated these into 40 verifiable best practice steps that we could implement with each patient undergoing this surgery. We hardwired these into our electronic health record so that we would be prompted to meet each identified step – or document the specific reason for any exception. We then established a package price that included costs of the first physician visit when surgery was deemed necessary, all hospital costs for the surgery, and related care for 90-days after surgery, including cardiac rehabilitation.

We named this program “ProvenCare”, since it is based on evidence or consensus of best practices by our heart experts. Pre-operative, post-operative and rehabilitation are part of the single charge. And we take the financial responsibility for any associated complications and their treatment. While our cardiac surgery outcome was already well above the national average, (and near the top of Pennsylvania’s PHC4 data set) upon initiation of this program only 59% of patients received all 40 best practice steps. Three months into the study, 86% were receiving best care. We raised that to 100% and, with few exceptions, have kept it at that high rate. As a result of implementing this “warranty” program, our patient care was better – using comparative, standardized data from the Society of Thoracic Surgery. We had a reduction in all complications of 21%, sternal infections were down 25%, and re-admissions fell by 44%. Costs for treatment fell, too. Our average length of hospital stay decreased by half a day4.

For other high volume, hospital-based treatments, we have now considered every step in the patient’s care flow. For instance, in orthopedic surgery, why should one doctor use one set of surgical instruments and prosthetic devices and another insist on a different instrument set-up for the same procedure? That type of variation often has no medical justification, results in unnecessary costs that are passed off to third party payors (such as Medicare) and, we believe, compromises patient outcome. We have expanded our experience with heart surgery to “warranty” programs that include:

  • hip replacement
  • cataract surgery
  • obesity surgery
  • prenatal care for babies and mothers (supported by the March of Dimes) – from an infant’s conception to birth
  • centrally- managed, evidence-based use of high cost biologicals, such as EPO (erythropoietin)
  • heart catheterization

We have improved outcomes and have reduced costs. This is because we have systematically researched how best to deliver care, hardwired the process steps into our electronic health record to prompt us on what best practices are, decreased unjustified variation, and taken financial risk to decrease related complications.

ProvenCare – Chronic Disease

In reforming how we deliver care at Geisinger, it isn’t enough to simply address acute episodic care. The major challenge of healthcare in the U.S. is now chronic disease treatment and “secondary prevention”. We identified the most common chronic diseases – diabetes, coronary artery disease, congestive heart failure, kidney disease – and have applied evidence or consensus-based best practice thought to limit disease progression. Called “bundled” care, we have designed each of these steps into our care pathways and strive to achieve as close to 100% adoption as medically appropriate and feasible. In the case of diabetes, we began to track how we performed in meeting 100% of the expected “bundle” of best care for diabetic patients three years ago. Our primary caregivers have chosen to receive compensation based on how many of their 25,000 diabetic patients reach optimal levels in the practice “bundle”, not solely on how many patients are seen each day or how many tests are ordered.

ProvenHealth Navigator (Advanced Medical Home) 3, 4

Geisinger’s patient-centered medical home initiative (called ProvenHealth Navigator) combines traditional medical home models with patient engagement and is designed to deliver value by improving patient care coordination throughout the system. Our Advanced Medical Home currently covers 30,000 Medicare recipients and 3,000 commercial patients, with plans to expand this base. We understand that navigating through the complexities of any healthcare system is not easy, so we have invested in programs and staff to help support each patient’s journey, placing dedicated nurses in each targeted outpatient clinic. Over 200 Geisinger primary care physicians diagnose and treat their patients locally in 38 community practice sites. Our “embedded” nurses are paid for by the Health Plan, becoming critical members of the community practice team and, with the physicians, are expected to know the patients and their families, to follow all of their care, help them get access to specialists and social services as necessary, follow them when they are admitted to a hospital, contact or see them when they are sent home to confirm that they are taking the appropriate medication dosages, and be available for advice 24 hours a day.

Importantly, we don’t just ask these community-based clinicians to “try harder” or “work faster”; we use resources from our health plan to help redesign their work. And, we pay incentives for getting the job done. In our best practices, our sickest chronic disease patients’ admissions were decreased by 25%, days in the hospital decreased by 23%, and readmissions following discharge decreased by 53%. The payback for the health plan occurred within the first year. The benefit to patients and their families avoiding multiple hospital admissions was priceless! For these patients with multiple chronic diseases, transport to and from the hospital or clinic, choosing which doctor should be seen, coordinating their numerous prescriptions, getting their pills, making sure they take their pills at the right time – all of this is what our ProvenHealth Navigator work redesign accomplishes. Increased quality for the patient and their families actually lowers healthcare costs.


Building on what we have done at Geisinger, I have these recommendations for your consideration:

  • Establish a simple, understandable set of national goals, so we can hold ourselves accountable together for improving the quality and value of health and healthcare for our citizens.
  • Change reimbursement to reward positive outcomes, not units of work.
  • Pay for episodes of care, forcing all providers to work together across physician and hospital boundaries to achieve optimal outcomes.
  • Pay more for delivering high value primary care.
  • Fund innovation to create real or virtual integrated systems of care.
  • Consider capitation payments linked to quality outcome measures for prevention and chronic care services.
  • Help fund enabling information technology but insist on non-proprietary interoperability.
  • Do not pay for mistakes and do not pay for care that is of no known benefit.
  • Help hospitals and communities establish transitions of care programs to reduce unnecessary admissions and readmissions.

Thank you again for the opportunity to testify today and I look forward to your questions.


  1. Walker J, Carayon P, From Tasks to Processes: The Case for Changing Health Information Technology to Improve Healthcare. Health Affairs, Vol. 28, No. 2, 467-477, 2009.
  2. Paulus R, Davis K, Steele G, Continuous Innovation in Health Care: Implications of the Geisinger Experience. Health Affairs, Sept/Oct 2008. Vol. 27, No.3
  3. Casale A, Paulus R, Steele G, et al ProvenCareSM. A Provider-Driven Pay-for-Performance Program for Acute Episodic Cardiac Surgical Care, Annals of Surgery. Vol. 246, Number 4, Oct. 2007
  4. Abelson R. In Bid for Better Care, Surgery With a Warranty. The New York Times. May 17, 2007.


Filed under Episode of Care, Health 2.0, Healthcare, Innovation, Leadership, Medical Home, Quality, Uncategorized, Value, X PRIZE

Primary Care Possibilities – Kaiser Leads the Way (again)

Leadership (lē’dər-shĭp’) n.

  1. The position or office of a leader
  2. Capacity or ability to lead
  3. Guidance; direction

I have written extensively about Kaiser Permanente in the recent past (here, here, and here) – not only for their notable achievements but even more impressive to me is their genuine interest to share their results with others as model for global health improvement. The recent issue of Health Affairs has two impressive articles from Kaiser regarding their EHR implementation as well as their Online Portal efforts. Great material.

As part of the same issue, Health Affairs newest contibutor Carleen Hawn highlighted the work of Ted Eytan in an article discussing the new social media delivery model. The article was a campy, highly conversational piece introducing some Millennial Vibe into what has always been the hushed tones of the highly academic/policy focused Health Affairs. Ted continues to do alot of interesting work, and in his role at Kaiser travels the country looking at new models of care delivery, new technologies, and the beautiful symphony that occurs when patients/physicians are working together in partnership to optimize health. A recent blog post of his highlights some of what he is seeing within Kaiser in terms of delivering more valuable primary care to patients. I thought it was worthy of re-posting large sections:

Because the innovation in primary care they are helping create involves all members of the care team, they created an experience for me that included shadowing physicians as well as nurses and clinical pharmacists. We should understand how every member of the team contributes, and this was great.

So what did I see?

  • Data systems and the workflow to support it are maturing to the point that primary care teams can understand how to keep patients healthy whether or not they actually come in for appointments. Teams are alerted about patients with chronic illness proactively, not reactively, more quickly than ever before. Medical and Nursing staff are responding to this new ability by creating new workflows and partnership around supporting patients, families, and populations.
  • Physicians are comfortable with the comprehensive electronic health record in practice: quote from an Ohio Permanente physician, “I don’t want the computer to get in the way (of the visit) but at the same time it’s a wonderful opportunity to share with the patient.”
  • Participation of a wider array of team members including nurses and clinical pharmacists, to leverage their skills, whether it’s coaching/teaching, medication management, all connected electronically (now).
  • Rethinking of the primary care practice altogether – including the idea that primary care physicians may see higher acuity patients as population management is spread across more staff, that they will use non-traditional communication methods including secure e-mail and telephone as part of what they do, and that managing a panel is work integrated into the day.
  • My favorite After Visit Summary workflow – every member whose care I observed got one – physicians and nurses work together to create and go over information with patients, it is not just a task of one or the other. They use the electronic health record to signal each other consistently for the handoff, which happens reliably. This helps accuracy and efficiency for the member and the system.

I think this work is not only useful for Kaiser Permanente, but for all of health care, because Kaiser Permanente’s financing model allows for this type of innovation, and sharing of such.

At the same time, there are major challenges here. The primary care provider shortage has affected Kaiser Permanente as much as the rest of health care. The good news is that this shortage is driving many of the innovations above, which I actually think will be portable to all of health care.

Wow. High performing health systems do more with less, do less for each patient (because the patients do more themselves), and involve a team approach given their aligned incentives all focused around a patient centered experience. I also love that they are willing and wanting to share their experience, to help others see the possibilities, and working together to improve our health as a nation. Isn’t that the essence of leadership?

Bravo, KP!


Filed under Change Agents, Innovation, Leadership, Medical Home, Quality

“Systemness”: Which Delivery Model is Best?

Systemness (sĭs’tə-m nes) adj.

  1. Arrange according to a system or reduce to a system
  2. The degree to which something shares the attributes of a system

Last week I attended the World Health Care Congress Consumer Connectivity conference in San Diego. The Twitter stream was at near flood capacity, and several excellent speakers were present to share their ideas. Conference attendance was affected by the economic climate but I believe the course of dialogue, the information shared, and value of the networking still proved worthwhile.

I shared a panel with Jordan Shlain, MD the founder and Medical Director of Current Health. I served as an advisor to the company through the late summer / fall and participated in their launch in December at World Health Information Technology Conference in Washington DC. Our presentation was intended to focus on “Millennial Technologies for the Medical Home” but given the light attendance, we essentially abandoned our traditional presentation given the intimate setting. After a brief introduction from me regarding the notion of Millennial Patients demanding Millennial Care, Dr. Shlain spent the balance of the session sharing some of the reasoning, thought, and opportunity behind the “direct practice” concept of Current Health.

During the presentation, several examples of “fortress medicine” were shared, including some which highlighted some individual failures and market perceptions with Kaiser and other large providers. The conversation took a couple of pointed turns as several Kaiser employees were in attendance (including an excellent Twitter follow in @janoldenburg). As Dr. Shlain would highlight individual cases which created opportunity for Current, they were countered by persuasive examples and initiatives from the Kaiser team. Abstracting out the tone, the content of the conversation was instructive in terms of alternative models of care.

Integrated health delivery systems deliver better results, period. The evidence is overwhelming as identified by the Dartmouth Atlas and countless other studies. We need to move our country to more “systemness”, which implies coordination, teamwork, shared learning, shared responsibility, and a long term perspective with aligned financial incentives. This is why I love the vision and the promise of true “health systems” like Kaiser, Intermountain Health Care, Group Health, Geisinger, and others.

However, Kaiser and all of these systems, are not perfect (nor claim to be) and despite systemic results that are superior there are individual failings (which seem to find their way into the sensational or anectdotal) that creat opportunities for viable delivery method alternatives. The notion of the medical home, or its complementary concept of Concierge Medicine, is also a “system” of care wherein a single physicians assumes the role of integration and patient experience. Assuming accountability to deliver this “virtualization layer“ enables these physicians to approximate the degree of integration that leads to better outcomes. These organizational delivery concepts have been created to remove the clinical and financial friction and frustration inherent in our current system and deliver personalized care that is safe, effective, patient-centered, timely, efficient, and equitable. We are also starting to see the positive results from these early studies.

The bottom line, we can no longer tolerate our uncoordinated, fragmented, silo’d delivery mechanisms. We must create “systemness” through all the appropriate means as any production organization has had to do as well. The culture of quality and outcomes must be built into the health care processes themselves and their must be rigorous, ongoing improvements with shared learning as the results are captured. This systemness, by any means necessary, will be good for our nations health.


Filed under Current Health, Direct Practice, Health 2.0, Innovation, Leadership, Medical Home, Value

The Health Care Levee – Community Clinics as Medical Homes for the Indigent

Levee (lĕv’ē) n.

  1. An embankment raised to prevent a river from overflowing.
  2. A small ridge or raised area bordering an irrigated field.

The medical home concept is going mainstream. Not only is it a significant part of the Obama teams reform agenda, but it has hitting the front pages much more frequently.  Of interest, Seattle continues to be the hotbed of innovation around this concept (interesting, they are one of the few states that have changed their laws to accomodate “direct practice” medicine), with commercial innovators like Qliance and academic institutions creating new types of practice models.

This article from the Seattle area highlights some early successes working with insurance companies to pay a monthly fee for (a new form of capitation?) services that are increasingly showing a major impact on health (increased communication, care coordination, population/preventative health, etc) but have never traditionally been compensated.

You will recognize this model, “fee for service with a capitated medical home fee” or “compensation for enhanced practice capabilities” (I will actually peel back the onion on what these “enhancements” really are), as the model advocated by Alan Goroll and his associates in Boston. Their model envisions the smoothest path to fundamental reform as being one that works within the current insurance paradigm but with several key improvements over Capitation 1.0. These would include compensation for the enhanced practice capabilites already noted, adjustments according to patient complexity, (they have a fairly elegant patient modifier algorthm), and tying a significant dollar figure to patient satisfaction and ultimately patient outcomes (when they become available). This is a workable approach as long as the payers come to the table which apparently is beginning to happen in Seattle (with at least 50 other “pilots” nationwide).

However, at the same time we are witnessing the above success, we are also seeing Primary Care Clinics being overrun, patients locked out, and system impassibly constipated in terms of new patients moving through.  Increasing access in Massachusetts did nothing to increase capacity. I fear the current economy will only accelerate this based on this report from the California Healthline. This will in turn hurt the most structural at risk part of our health care system – the community  health clinic. These often under-funded, under-staffed, overcrowded, and overburdened facilities are home to some of the most noble of the entire profession who day in and day out slug it out in some very difficult trenches. But they are also some of brightest, most resourceful, and talented clinicians and healers we have in medicine. They represent the levees of our American Health Care system.

But their limited surge capacity will most certainly be overwhelmed in the coming flood of patients being sent their way by the prevailing financial storms. When the flood waters break, I believe Katrina will look like an afternoon shower compared to the vicious cycle of care that will ensue (no primary care, crash in the ER, most expensive place to treat, kicked to the street, no followup, and back to the ER. Rinse. Repeat. Ad Nauseam and Ad Infinitum). Ouch.

Louise McCarthy, vice president of governmental affairs for the Community Clinic Association of Los Angeles, said, “There’s not a very large infrastructure in place to handle the increasing need, even though providers will do everything they can to treat as many people as they can.” Sounds reassuring.

Given that the Community Clinic is the “medical home” of the indigent – what low cost, effective, and useful technology sandbags can be put cobbled together to hold back the waters? I like David Kibbe’s recommendations to Obama as examples of the simple, but far reaching processes that can be implemented to complete the growing support for ubiquitous EHR deployments (about time!).

What other sandbags, or better yet, what infrastructure needs to be put in place to service the Community Health Clinics as a fundamental component of our primary care system?

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