Patient-Centered, Clinically Integrated, Care Delivery

INTRODUCTION

The future success of the US healthcare system will rely on our ability to reimagine the delivery system from the ground up and design it in a way so that it reliably delivers high value, which I define as quality per unit of cost, to the patients it serves.

The Covid-19 pandemic has revealed in gory detail the many defects which exist in our current system. Lack of access to care, high costs, substandard clinical outcomes, and large gaps in areas such as public health and epidemiology are just a few of the major issues that must be addressed.

I am arguing for the development of a patient-centered (as opposed to the provider-centric, profit-oriented model within which we now operate), clinically integrated (clinically integrated networks focus on high-value care delivery as opposed to high-volume care delivery), and provide the infrastructure necessary to deliver such care.

This article will describe in detail what such a model should look like and how it should function. I envision it being constructed, not in a top-down fashion, but instead, through a decentralized, ground-up process that respects the fact that healthcare delivery is not uniform. Indeed, each patient entering the healthcare system comes with their own unique set of perspectives, cultural beliefs, socioeconomic blessings or needs, clinical issues, and a multitude of other variables. Providers who claim that “this won’t work in my practice” will be taken at their word and allowed to devise care processes that they believe will work with their particular patients, staff, facilities, equipment, and available resources. The patient-centered, clinically integrated (PCCI) delivery model will not be a one-size-fits-all approach.

A unique feature of the PCCI delivery model will be that it will not only function differently from the current system regarding clinical care delivery. It will also function to reform the economic milieu in which healthcare now operates. I envision each PCCI model functioning as both a provider network and a payer of healthcare services. This will align providers and payers and allow a rapid shift to value-based and away from volume-based care delivery by providers and payers alike.

Features of the PCCI model, which will be explored in more depth in the following sections of this paper, will include:

1. A uniform approach to care process design and data-driven performance improvement over time.
2. A uniform approach to quality measurement, where providers can choose metrics that they feel reflect the quality of care provided to their patients.
3. A uniform approach to cost measurement, where true costs of care delivery (as opposed to poor proxies for costs, such as charge to cost ratios RVUs or even worse, payments from payers) are used to measure the cost component of the value equation where Value=Quality/Cost.
4. A uniform approach to contracting, where different PCCI networks will bypass traditional payers and directly contract with employers, populations, and individuals to provide care across the spectrum from ambulatory to inpatient and from preventive, to acute, to post-acute. This contracting will involve various forms of value-based reimbursement or what have now become known as alternative payment models to include bundled or episode-based payments, shared savings agreements, at-risk population health management contracts, and others.
5. A uniform approach to PCCI model structure and governance, where key components will include — clinical leadership (particularly from physicians); collaboration with others who respect the fact that medicine today is a true team sport; transparency of data down to the individual provider level; accountability for those unwilling to commit to the drive toward value-based, patient-centered, care delivery; retention of a competitive environment (where competition around the provision of high-value care is the goal as opposed to competition around patient volumes or profit margins); and involvement of patients around whom all aspects of a high-value system must revolve.

NOTE: The uniform approach that will be described in this article involves the structure and function of the PCCI and does not imply that a uniform or standardized approach to clinical care delivery is always best. While there are some procedural areas of medicine where standardized care is appropriate, the PCCI model will not advocate this for all areas and instead, as stated above, foster a localized and customized approach to the design of care processes.