|
For the past several years, Kaiser Permanente has been
fundamentally redesigning primary care delivery in Georgia. We have
built a unique model centered on physician ownership and accountability
along with incentives and compensation levels which are tied to performance
and member satisfaction. Structured around small, semiautonomous teams,
this model blends the best of two worlds by leveraging the scale, structure,
experience, and reputation of the nation's largest and most respected
health maintenance organization (HMO) to create and support small teams
of medical professionals who manage the care of a defined panel of patients.
Introduction: The Challenge
Kaiser Permanente in Atlanta, Georgia (KP-Atlanta) began operations
in 1985, and by 1992 there were more than 156,000 members enrolled. The
plan had accumulated operating debt of approximately $80 million at a
time when competition was intensifying. A 1993 study showed that our internal
cost for delivering primary care was about 40% higher than in community
practice. Our competition was delivering primary care much more efficiently,
and our predictions suggested that our price disadvantage would increase.
The Primary Care Redesign Model
To meet these challenges, in 1993 KP-Atlanta developed a turnaround
plan which focused on three building blocks of successful prepaid group
practice: open access to care, increased productivity, and a physician
workday policy which defined a minimum number of hours per day which each
full-time physician or associate provider (nurse practitioner or physician
assistant) would devote to providing direct ambulatory patient care.
A fundamental component of this turnaround plan was major
redesign of primary care centered around development of health care teams.
Although the initial intent was to find new efficient methods of delivery,
perhaps even more important was that this redesign ultimately became a
vehicle to improve patient satisfaction and to make marketleading quality
improvements.
After about a year of assessment and design, in 1995 we
implemented a 6-month pilot program at one of our facilities, followed
by implementation of the program at our nine medical facilities over the
next 18 months. Throughout the implementation process and at every operational
level, all physicians or other employees were required to reapply for
positions on the team and to participate in a behavioral interview. In
behavioral interviewing, applicants are asked to give specific examples
of their past experiences which would show high probability of possessing
skills necessary in their positions. For instance, all health care team
leaders and facility managers were interviewed and were evaluated for
skills in leadership, coping, and making decisions.
Our next step before further implementation was to install
the leadership positionsfacility managers and health care team leaders.
First, for each facility we selected management teams consisting of a
physician-manager and a medical center administrator. We made it clear
that all facility managers were required to reapply for their old jobs
without any guarantee of reappointment. The primary competency requirement
for these middle managers changed from direct line management to coaching
and mentoring health care teams to support their increasing autonomy.
Next, senior managers and these facility managers participated in behavioral
interviewing of applicants for the 24 physician health care team leader
positions, during which time they were asked specific behavioral questions
about management skills believed to be important in managing the new teams.
After the health care team leaders were in place, they in turn initiated
a selection process for their lead nurses by soliciting applicants for
these positions. The positions prompted a high level of competition, and
many nurses were willing to change facilities to become lead nurses. After
being chosen, the lead nurses and health care team leaders posted the
positions for providers and other team employees. Again, multiple applicants
were considered for every position, and only the most suitable were chosen.
Training of our teams was very detailed during implementation
of the program, which occupied eight full days for each team. Teams were
therefore unavailable to provide patient care during the training period.
This entire implementation process took place throughout
KP-Atlanta in 1996, and all health care teams were in place by the beginning
of 1997. Throughout 1997 and 1998 we expect to continue implementing major
pieces of the primary care redesign, including introduction of more advanced
technology and new compensation systems.
The Health Care Team
A team-based approach to primary care is at the core of our
primary care redesign and is embodied by health care teams (Fig. 1). All
24 teams are led by a physician who is accountable for the team's budget
and overall operations. Although a team staffing model was developed,
in reality we allow each health care team leader to determine makeup of
the team as long as the team stays within budget. Team members center
their duties around caring for the panel of patients assigned to the team.
This panel concept facilitates population management, and we expect that
by providing personal and satisfying care, our teams will "grow"
their own membership as part of their business strategy.
 |
| Fig 1. |
How does a fee-for-service practice expand its business?
Stated differently, why grow a practice? We want the same outside community
economic issues to affect each health care team. Specifically, a team
can increase its revenue by increasing the number of patients on its panel.
Issues of revenue appropriation (e.g., determining number and combination
of providers, nurses, or other employees or nurses which will make up
the team) will be decided at the health care team level. In addition,
compensation arrangements will allow incentives to be offered for the
team to optimize productivity and will no longer impose divisional directives
in areas such as patient scheduling.
For our patients, value is created at the team level, and
our new health care teams will not succeed unless they continue to provide
highly personal, accessible care which produces defined, measurable, high-quality
outcome. In the past, KP-Atlanta improved access to care by initiating
a work policy which required all physicians and associate care givers
to provide direct patient care for at least the defined minimum number
of hours daily. In the future, each health care team will define the time
and modality of care needed to meet the demands of each team's panel of
patients. The health care teams become successful by increasing the number
of members assigned to their team and then providing satisfying care to
these members. The divisional administration is developing the skills
necessary to measure the outcomes and patient satisfaction and to use
the results to measure success of the health care teams. Each team will
be given this information to aid in evaluating its own performance.
Technological Support
Throughout KP-Atlanta, electronic medical recordkeeping (Fig.
2) is a high-priority goal which, when achieved, will greatly assist in
managing each health care team's panel of patients. The plan is to introduce
a pilot version of the electronic medical record in 1998 with full implementation
regionwide pending results of the pilot. The electronic medical record
will be integrated into the laboratory, pharmacy, and radiology department
systems, the referral system, and a new physician profiling system. The
profiling system will allow us to more accurately determine acuity and
panel size for each health care team. Although the technology will mainly
facilitate medical care provided by our health care teams, it will also
aid in measuring team performance when evaluating in the health care teams.
These new forms of technology can measure both cost and quality of performance.
 |
| Fig 2. The electronic black bag of the
future. |
Telemedicine
The ability to provide daytime advice by telephone is incorporated
into the health care teams; after hours, advice is provided by a regional
call center, a leveraged service started in 1996 which is also a centralized
provider of appointments.
Telemedicine expands patients' access to care while improving
efficiency at the health care team level. A study clearly showed that
our patients responded positively to being given an appropriate appointment
by telephone. Since then, we have encouraged our health care teams to
schedule telephone appointments; currently, most are doing so at a rate
of about two appointments per session with a patient. We envision many
health care teams expanding the use of the telephone appointment to provide
efficient care to its panel of patients.
Complete, Integrated Care
As mentioned, our health care teams are encouraged to take
responsibility for the panel of patients assigned to them. We expect the
health care teams to involve patients as much as possible in their own
health care decisions. This kind of care should become more personal,
more realistic, and rely less on referrals. For our patients, this style
of practice should create real value: care becomes less fragmented and
more personal, and the health care team assumes clear-cut accountability
for its performance. This concept represents the new frontier of health
care delivery, and education of our primary care providers is its cornerstone.
Physicians practicing both in primary care and in specialty areas have
created and agreed upon clinical guidelines whose appropriate use can
be measured in ascertaining the health care team's success.
Disease Prevention and Early Intervention
The primary care redesign model emphasizes disease prevention,
early intervention, and disease management by each health care team. Accordingly,
health care team training emphasized disease prevention and early intervention
as well as other elements of the team's duties: Prevention programs such
as for smoking cessation, breast cancer screening, management of acute
low back pain, and ensuring child immunization were discussed in detail.
Each health care team was trained in member communication and follow-up
procedures specific to the identified intervention programs. We expect
that in the future, incentive programs for health care teams will be aligned
around accomplishing certain prevention and early intervention goals.
Budgets and Incentive Programs
Each health care team's budget is capitated and allows for
capitation surplus to be gain-shared (Fig. 3). Total compensation is linked
to patient satisfaction and to quality of outcome. This arrangement encourages
increase in size of the team's patient panel while ensuring high-quality
performance and increasing patient satisfaction. The Board of Directors
for The Southeast Permanente Medical Group has recommended adding a flexible
component to the standard salary system which would allow a portion of
each provider's compensation to be flexibly distributed according to productivity,
patient satisfaction, and quality of service, with each service setting
its own performance measurements. Because each physician health care team
leader must understand the business principles involved in compensation
and in capitation, practice consultants have been hired to work with these
physicians to expand their knowledge of budgeting, capitation, and general
office efficiency. Most of the 24 physician-leaders are inexperienced
in this area, so we have embarked on a rigorous management training program
for all of them. Certainly not all physicians are natural entrepreneurs,
and part of the challenge is to create sufficient knowledge of good business
practices at the health care team level.
 |
| Fig 3. |
New Management Structure
During the redesign process, we realized that the traditional
Kaiser Permanente management structure would not support this future model;
for this reason, a new management structure was created specifically to
support the concept of semiautonomous health care teams. This management
structure supports and fosters physician ownership and team accountability
for high-quality health care, patient satisfaction, and office efficiency.
As mentioned, each health care team is led by one physician to whom the
team's other physicians, providers, and personnel report.
Middle management at the facility level has also experienced
an important change as mentioned, with its primary responsibility being
to mentor and facilitate development of each health care team. Success
of these managers will be measured by success of the health care teams
in their facilities.
At the senior level, an associate medical director for primary
care has been established to oversee the entire primary care redesign
and its implementation.
Summary
We have created a model of health care delivery which emphasizes
physician ownership and accountability. Empowerment and innovation have
been encouraged while maintaining Kaiser Permanente's long-standing value
to the community. Each health care team has been encouraged to become
a semiautonomous business unit making its own decisions about how care
is delivered to its patients. Concurrently, the regional administration
is improving its evaluation of team performance, patient satisfaction,
and quality. Ultimately, such evaluation should enable each team to align
its compensation system toward persons or groups on the team who show
the highest levels of quality, satisfaction, and efficiency.
The overall impact of our primary care model design has
been profound. Clear accountability at the health care team levelmost
specifically, accountability of the physician health care team leaderhas
created an atmosphere of physician ownership and accountability not seen
before in KP-Atlanta.
Although health care teams are now in place throughout KP-Atlanta's
nine medical centers, the primary care redesign effort is far from complete.
Computerized medical recordkeeping and other technological initiatives
are yet to be fully implemented. However, even more important is the transition
we can only term "cultural change," which we have found to be
a slow, stepbystep process. The challenge has been to focus on the end
state: a delivery system where quality is improved and patients are cared
for efficiently in a serviceoriented, memberfriendly way. With such a
system in place in Georgia, Kaiser Permanente will be ready to meet the
health care challenges of the future.
|
