This is a qualitative study of innovation in a region incubating a variety of patient-centered innovations. Participating organizations were chosen because they were implementing or preparing to implement one or more patient-centered innovations, and because they represented a broad range of health care organizations. Patient-centered innovations were not often specified as strategic goals per se. However, organizations’ top priorities, such as survival, cost containment, and quality improvement, were consistent with patient-centered care. Reflecting the variety of organizational structures, each organization was unique in its set of goals and strategies despite a degree of shared interest in aligning incentives and developing ACOs.
We attempted to represent faithfully the ideas presented by the interviewees. For example, while managing chronic disease is an aspect of appropriate care delivery, we did not assume that provider organizations shared the goal of appropriate care delivery with health plans because it did not emerge explicitly in the interviews. This methodology may, on the surface, divide themes that actually overlap. It is important to keep in mind the missions of the organizations to which themes are attributed.
We anticipated that organizations with different structures -- the independent practice association versus the multispecialty groups, or public versus private health plans -- would have different methods and approaches to patient-centered innovation, and this was the case. For example, executives at the provider organizations described many similar strategic objectives and visions, but the primary care practices affiliated with those organizations varied in their alignment with the parent provider organization’s vision. For example, the independent practice association providers rarely discussed the IPA leadership’s goals or strategic initiatives, while the multispecialty group providers referred to the leaders’ goals repeatedly – suggesting a greater degree of integration between affiliated practices in the multispecialty groups, as compared to the IPA.
Goal selection was influenced by particular organizational leaders, the culture of the organizations, organizational structure, and especially external drivers. This is a dynamic time for patient-centered innovation in Washington State, with the rollout of PPACA underway, multiple ongoing state-sponsored demonstration projects, a fragile economic recovery, and severe, continuing state budget constraints. The organizations’ goals were a balance between ongoing mission-critical objectives, like quality improvement and organizational survival, and adaptations to the current fiscal, competitive, and regulatory environment, such as transitioning to PPACA implementation.
Across health care organizations, a principal barrier to successful innovation was fee-for-service, or “pay-for-production,” provider compensation as well as the misalignment of financial incentives between health plans, providers, and patients. Organizations struggled to find material, financial, intellectual, and creative space for patient-centered innovation within the fee-for-service system – the “hamster wheel.” Hallmarks of patient-centered care are prevention and proactive outreach. These are absent from the current organizational-financial model (Figure ), but they are central to a sound, patient-centered delivery model, perhaps accomplished through ACOs (Figure ). Both health plans and provider organizations were willing and eager to try new payment and risk-bearing systems, but they will need financial support and legal leeway to test these delivery and reimbursement models.
A comparison of current fee-for-service payment system (a) with a theoretical accountable care organization health system structure (b).
The principal challenge in crafting policy is to find where organizations would not go on their own but could be coaxed or directed to do so for the public good with the right mix of cost-effective incentives and regulations. This study has helped to illuminate the factors that influence innovation, including leadership, organizational culture, and external drivers. Importantly, though, we found that organizations employed strategies and faced challenges that reflected their place in the health care market. For example, primary care clinics used work process changes rather than payment and benefit redesign, which were used by health plans, to enhance chronic disease management and quality improvement; health plans felt restricted by regulations while provider organizations cited human capital deficits as barriers.
The correlation between an organization’s ability to change an aspect of health care delivery and that organization’s choices of goals and strategies was expected, but striking nonetheless. With the exception of ACOs, the primary innovations happening in Washington State reside within each organization’s respective place in the spectrum of health care delivery and financing: shared decision-making and patient-centered medical home innovations are fundamentally at the provider level, while payment reform starts with regulations and health plans without requiring much provider input. Given that the organizations in our study are largely thinking about goals and strategies within their spheres of influence, it will take some out-of-the-box planning and/or higher-level leadership to make ACOs or comparable reforms possible.
The connection between an organization’s capacity and its chosen strategies and anticipated challenges also means that intra-organizational patient-centered innovations will either have to match health care organizations’ capabilities, or that organizations’ capacities must be bolstered, or both. In the coming new age of ACOs and integrated health care payment and delivery, a golden opportunity exists for each organization to make the best use of its capabilities and to partner with organizations that can make up for its deficits.
Concordantly, basic organization cultural and business norms, such as proprietary protections, will have to adapt in order for organizations to form effective ACOs, which rely on transparency and coordination between organizations. The shift from misaligned incentives under fee-for-service (Figure ) to aligned incentives of ACOs (Figure ) will aid in changing cultural norms of health care organizations, and we can glean some encouragement from providers’ rapid response to Medicare’s prospective payment (Diagnosis Related Groups) rollout in the 1980s [19
]. Still, we can expect the transition from competitive to cooperative cultures – as distinct from behaviors – to be slow, and the specific path to forming these cooperative networks is challenging to conceive [22
Limitations and future research directions
By design, this qualitative study centered on a “deep dive” within a small, purposive sample of organizations (health plans, provider organizations, and their affiliated practices) in a particular state context. While this focus in a specific environment and selected organizations generated rich learning and a unique “proof of concept” of patient-centered innovation, the enhanced internal validity and insights from this approach must be weighed against potential limitations in generalizability to care settings in other contexts. Future research should apply the constructs of this extended qualitative study in large sample, multiple setting, and quantitative studies of patient-centered care.