As a new decade approaches, the health landscape seems to be poised
for a resurgence in integrated health care delivery systems. Not
necessarily the traditional health plan PSO model, but instead a
model incorporating and embracing current concepts including medical
homes, bundling, new technologies, accountable health care
organizations and other key issues, Join Peter Kongstvedt, MD and
Roy Goldman, PhD, as they discuss the state of, and future direction
of integrated health care delivery systems, including a case study
addressing the perspectives, direction and initiatives of Geisinger
Health Plan and the Geisinger Health System.
Here's what national expert Peter
Kongstvedt, MD had to say about integrated health care delivery
system emerging trends and developments in the current issue of
MCOL's Thought Leaders:
"Many integrated delivery systems (IDSs)
in the past grew strictly in response to the rise of HMOs and were
created primarily as negotiating organizations. Beginning in the
mid-1990s, many began to take on capitation risk for all services,
including becoming Provider Sponsored Organizations (PSOs),
receiving full capitation directly from Medicare. The results were
disastrous for many of them, though less so in California where IDSs
had greater experience. As a result many early IDSs and almost all
PSOs fell apart, which was not a distant fall since they'd barely
integrated to begin with. For those who remained, the slow decline
in HMOs meant capitation became less prevalent and the ability for
well integrated IDSs to gain financially diminished. We're now
seeing a small uptick in HMO growth due to the economy, which could
be good news for truly integrated IDSs, but there are better reasons
to be optimistic.
The political debate over health reform began as one over cost, and
then cost combined with access to care. That it has drifted solely
to access and the vilification of health insurers was completely
predictable based on political reality since insurers are perceived
as the ones who say "no" while everyone else says "yes." But since
the pressures facing the health sector are both real and far
stronger than any rhetoric or demagoguery, problems with cost,
quality and adherence to evidence-based medicine will be little
affected by simply reforming access to insurance. Those problems
will require we actually change how we do things today, and the
financing system will need to change to support that. Early probes
into this include the confusing multitude of pay-for-performance
programs, and more recently the promulgation of Patient Centered
Medical Home by the professional associations of primary care
physicians, and pilots for Accountable Care Organizations by CMS. In
both of these latter approaches, significant resources are required
for coordination of care, making all relevant clinical information
available to the entire team of providers, and the use of
non-physician providers.
This all requires more than just an EMR, as described more clearly
in "Coordination of Care by Primary Care Practices: Strategies,
Lessons and Implications" (Center for Studying Health System Change,
Research Brief 12, April 2009) and demonstrated in a recent paper by
Felt-Lisk, Fleming, Natzke, and Shapiro, "Using Payment Incentives
to Improve Care for the Chronically Ill in Medicare: First Year
Implementation of the Medicare Care Management Performance
Demonstration" (MCMP, March 4, 2009). Seriously and continuous
improvement in outcomes and costs is best done by organized systems
that have not only the resources internally, but have a culture of
team work, as illustrated in a paper by Reider and Frick, et al,
"Guided Care and the Cost of Complex Healthcare: A Preliminary
Report" (Am J Manag Care. 2009;15(8):555-559).
As a result, many primary care physicians have sought shelter by
becoming hospital employees. If for no other reason than this,
systems with newly grown primary care practices are well able to
begin to form the nucleus of a truly integrated system or else
strengthen one already in existence. The slow decline in solo
practice and the growth of group practice parallels this. In both
cases, having more physicians working together allows for the types
of organization changes and infrastructure that can support truly
integrated systems. What we need to do is incent them. Truly incent
them. The deeply flawed existing fee for service system
preferentially rewards procedures and seriously underpays for the
types of services required in a truly coordinated system. It is in
all of our interests, as consumers, as politicians, as clinicians,
as decent human beings to help foster this growth, to push ever
harder for proper alignment of financing to support it, and to
demand of public leaders that they make this one of their highest
priorities, either as part of the current debate or after the circus
leaves town at latest."
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Peter R.
Kongstvedt, MD, FACP
Principal, P.R. Kongstvedt Company, LLC
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Dr.
Kongstvedt is a highly regarded independent national
authority on the health care industry with particular
expertise in health insurance and managed health care. He is
a Clinical Professor in the Department of Health
Administration and Policy, School of Health and Human
Sciences at George Mason University, where he teaches a
graduate course on the topic of Health Insurance and Managed
Health Care. Dr. Kongstvedt also is principal of the P.R.
Kongstvedt Company, LLC, a firm advising health care
executives on strategy, operations and effective decision
making to achieve greater success. He is also developing
electronic multimedia training and education programs for
several health sectors, in partnership with Metrix Group.
Peter is the editor and primary author of three seminal
works on managed care: The Managed Health Care Handbook,
which he first wrote in 1985, while the fourth and final
edition of this landmark textbook was published in 2000; The
Essentials of Managed Health Care, Fifth Edition (published
2007); and Managed Care: What It Is and How it Works, Third
Edition (published 2008). These books are widely considered
"the bibles" on managed care and are extensively used in
over 230 colleges and universities nationwide, in corporate
training and educational programs, and as a general
reference book within the healthcare industry. He also
co-authored Best Practices in Medical Management with David
Plocher, M.D. in 1998.
Peter began his career by practicing general internal
medicine in rural southern Illinois at a rural health
initiative clinic. After practicing for three years, he
moved to Lincoln, Nebraska to be the medical director of a
medical group associated with a group-model health
maintenance organization. Soon after he became its chief
executive officer as well.
He continued his successful career as an executive in the
managed health care industry, assuming increasingly
responsible positions through 1993 when he held the position
of executive vice president and chief operating officer at a
Blue Cross Blue Shield plan in Washington, DC. In that same
year, he became a direct-admit partner at Ernst & Young LLP,
and continued his consulting career with global firms such
as CapGemini and Accenture until 2008 when he formed the P.R.
Kongstvedt Company, LLC.
Peter is a regular speaker at industry and trade group
conferences as well as health care companies. He is also a
frequent contributor to publications and the media, has
appeared on PBS and CNN as well as local media, and was
recently asked to be a national advisor to The CBS Evening
News with Katie Couric on health reform, health insurance
and managed healthcare. He also serves on the advisory
boards of five industry publications. |
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Roy Goldman, Ph.D., FSA, MAAA, CERA
Chief Financial Officer
Geisinger Health Plan |
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Roy Goldman, Ph.D., FSA, MAAA, CERA, has served as chief financial officer for
Geisinger Health Plan since 2006. Goldman has an extensive
background in health care, previously working as the chief
financial officer for Mercy Health Plans in St. Louis, Mo.,
and as senior vice president, chief financial officer and
chief actuary for Prudential Health Care Group of the
Prudential Insurance Co.
Prior to that, Goldman was
an assistant professor at Rutgers University. He graduated
cum laude with a bachelor of arts from Franklin and Marshall
College where he was a member of Phi Beta Kappa. He received
his Ph.D. from Rutgers University in mathematics. Goldman is
a Fellow of the Society of Actuaries (FSA) and a member of
the American Academy of Actuaries (MAAA).
In 2005, Goldman was named
Financial Executive of the Year in a five-state region that
included Missouri. He has dedicated 30 years to actuarial
education, served as treasurer for the World Affairs Council
in St. Louis, and was elected twice to a local school board
while living in New Jersey. |
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