There are, of course, major hurdles and risks associated with moving from the current system toward True North. The most obvious, of course, is that the payment structure of Medicare and most major managed care organizations remains encounter based, which makes investment in efforts to optimize health and decrease encounters financially self-destructive. In addition, the process of assembling a like-minded team of physicians and other health care professionals involves moving from the old “workshop” model of hospitals in which each physician represented a potential source of referrals even if she/he split efforts among multiple health care organizations and had no enduring relationship with or interest in the success of any one hospital entity. As health systems build greater physician alignment, they leave behind physicians with whom they have a marginal affiliation but who nevertheless represent patient volume with a positive financial contribution margin.
Despite these risks, SSMSL has chosen to embark on the path toward True North but in a manner designed to reduce the magnitude of the risk undertaken. It has chartered a set of teams to work in concert on various aspects of the transformation and is attempting to synchronize, to the extent possible, the financial structure of payment systems with the operational aspects of redesign. Teams are chartered in the following areas.
This group is charged with identifying and developing formal relationships with like-minded physicians and other health care professionals using multiple alignment models including employment, professional service agreements, and comanagement arrangements. As part of this group's effort, they are defining the “covenant” that sets forth the expectations for participating health care professionals and reflects the vision of True North.
The charter for this team is to design and deploy the means through which the participating health care organizations will govern this enterprise, in whatever form it ultimately takes, to ensure alignment and integration of the interests of all parties in transforming care delivery, contracting, and the flow of funds.
This group is charged with identifying the areas of most significant clinical improvement (and existing waste) to focus efforts toward early improvement of value. Having identified those “first-generation” areas of improvement, the group then coordinates among participating health care organizations the design and deployment of tools and infrastructure to achieve improved performance, as well as the tracking mechanism and accountability systems needed to support performance improvement. The initial focus identified by this group includes the management of chronic disease through the deployment of a patient-centered medical home model, unnecessary admissions through the emergency department, avoidable readmissions, inpatient care variation, and transitions of care. Over time, this group will expand its focus to address other areas of improvement opportunity.
This group, focused on the identified areas of clinical improvement, is responsible for redefining the terms of economic models involving all payers in order to reinforce efforts at improvement and reward improved performance. This includes revised contracting with commercial and Medicare Advantage managed care organizations, restructuring the SSM employee health plan, response to Medicare's Value-Based Payment provisions, exploration of pilot programs with CMMI, and potential direct-to-employer contracting. This group was also charged with evaluating participation by SSMSL in the MSSP and the Pioneer ACO.
Information Technology and Application
The focus of this group is to develop information technology (IT) and decision support tools that align, once again, with the first-generation areas of focused improvement. While ideally all participants would share common information systems, the practical reality is that in the immediate future there will need to be a level of coordination to share critical, time-sensitive information across multiple systems. This group is charged with developing both a pragmatic view of immediate IT infrastructure needed to support the areas of focus and developing the long-term vision of the ideal IT architecture to drive integrated care.