This article appears in the May 2012 issue of HealthLeaders magazine.
Editor's note: This piece is an excerpt from a fuller case study that is part of an upcoming Rounds event, Building ACO Foundations: Lessons From Kaiser Permanente's Integrated Delivery Model. To see the full case study, which includes additional lessons and more information, visit www.healthleadersmedia.com/rounds/.
No hospital or medical group would dare admit they do not practice team medicine, at least conceptually. But true team medicine is about more than an aspiration—it's an intentional structure built, led, and enabled to deliver care by a diverse, multidisciplinary team of physicians, nurses, pharmacists, counselors, and dozens of other professionals. Oakland, Calif.–based Kaiser Permanente, even with its massive scale of 8.9 million health plan members, more than 16,000 physicians, and 170,000 employees, is built around the team medicine concept.
To be sure, there are benefits to Kaiser Permanente's integrated structure, which allows aligned incentives between the Kaiser Foundation Health Plan and hospitals and the Permanente Medical Group physicians. Still, Kaiser Permanente leaders say the key to creating team medicine is less about alignment around reimbursement and more about a commitment to a different way of practicing healthcare, not just medical care.
Amy Compton-Phillips, MD, an internist and associate executive director of quality for the Permanente Federation, says team medicine requires thinking about the physician's role in a new way.
"Twenty-first century medicine has shifted from the solo clinical expert model to one where physicians serve as a leader of a healthcare team to focus on the total health of our patients," Compton-Phillips says. "The team works together to coordinate care seamlessly across specialties, settings, and disciplines."
When the patient engages with an entire team, it frees up all sorts of opportunities for improved outcomes and cost savings, says George C. Halvorson, chairman and CEO of Kaiser Permanente.
"Ideally you have the patient who sees their primary care site, their medical home, as their primary and central coordinating caregiver," Halvorson says. "And those sites function best if they're team-based and they've got doctors and nurses working together."
Team assignments are based on who is the most appropriate. "It doesn't necessarily have to be the physician speaking with a patient about a request for new prescriptions on the phone. Having a nurse calling and creating a little dialogue works very well and is more efficient," Halvorson says.
One of the criticisms leveled against team medicine is that it can have the adverse effect of diluting ownership, that because everyone has responsibility for the patient, no one has responsibility for the patient.
Murray Ross, PhD, vice president and director of the Kaiser Permanente Institute for Health Policy, says, "It's all about accountability. You have one entity accountable for the patient rather than five to seven entities that are all individually accountable, which means that none of them are. If there's no one in charge, there is no one to say, 'What should we be doing for this patient as a team?'"
Without a team structure, there is no incentive or method to look for care gaps that could cause more complications or expense for the patient, says Benjamin K. Chu, MD, an internist and group president of Kaiser Permanente Southern California and Hawaii.
"It is so important to have a mirror held up to us that forces us to look at our system as a whole," Chu says. "If you just say, 'It's your responsibility to do this, Dr. Primary Care,' or 'It's your responsibility to take care of these things, Dr. Hospitalist,' it's just not going to happen. There's no way that individuals acting alone can close those gaps or solve those problems."
Along with accountability has to come tools so that all members of the team know what the patient needs—sometimes even before the patient does.
"If you call up our call center to make an appointment, the call center agent will actually have a list of the gaps in your care plan," Chu says. "So, for example, if you haven't had a cancer screening or a mammography, or if your blood pressure has been out of order, they'll actually try to arrange for follow-up for you on the phone."
Beyond tools and accountability is the culture of team medicine, one that many physicians whose medical education and training have been built around a physician-centric model can be slow to embrace. Jack Cochran, MD, a plastic and reconstructive surgeon and executive director of the Permanente Federation, says he often hears Kaiser Permanente has been able to make significant strides only because of its model.
"I don't accept that," Cochran says. "We have made a concerted effort to learn and make substantial improvements in our care and outcomes over time. Our physicians combine professional satisfaction with a strong commitment to the mission of the organization. What is necessary is to move beyond self-interest. The physicians have to ask themselves, 'What is my personal mission?'"
The Permanente Medical Group is built around a core set of values and expectations. "We recruit physicians with a sense that we're a group practice. We stand for quality. We measure quality and results," Cochran says. "We think it's important that we tell patients we're going to give them the kind of quality they deserve. You then orient, evaluate, and promote people based on the same set of values and expectations. Eventually you end up with a culture that is very comfortable with a focus on quality, measurement, comparison, and improvement."
Robert Pearl, MD, a plastic and reconstructive surgeon and executive director and CEO of the Permanente Medical Group, says in a typical Kaiser Permanente referral, "our integrated delivery system structure allows the patient who, for example, needs orthopedic expertise to obtain it rapidly. We have the ability today for the primary care physician to call an orthopedic surgeon while you're in the examination room. We have the ability to offer you a same-day visit or to offer you a visit on a different day."
In a community-based medical staff model, Pearl says, the primary care physicians cannot get immediate assistance since they would need referral links to all of the orthopedists in the community, not just one or two. And they would need to have the phone and scheduling system integration to be able to offer the same-day schedule.
The team concept extends to acute hospital care, as well, Pearl says. His group realized it needed a specific team of physicians, nurses, and technicians to handle sepsis, which is the No. 1 killer of patients in the hospital, Pearl says. "You need a full sepsis team 24/7, able to respond to the emergency room immediately because the treatment is very complex and somewhat dangerous, but the result of doing it in the most timely fashion is you save the lives of a significant number of patients."
The early signs of sepsis can be difficult to diagnose, particularly with young people, Pearl says. "You need to have the expertise to draw appropriate laboratory tests, to provide high fluid administration and placement of central lines, and to provide intense treatment on a consistent basis for patients who at that moment don't look particularly sick, but you know they will be in 24–48 hours. To do that well requires a team of individuals with a broad skill set—physicians and nurses and other individuals who come to an emergency room, see a patient, and begin the treatment—because if you just let everyone do it who doesn't do it often enough, it's too late and the results are not as good as they could be."
The business model for most of healthcare today does not support team care. Typical fee-for-service reimbursement discriminates against the type of coordination that team-based care often requires, Halvorson says. But once the reimbursement plates have finally shifted and necessary tools are put in place, team medicine can have enormous power, he says.
"The business model has to support team care by paying for all the pieces," Halvorson says. "And then if you have the right computer system, the right care registry, and you've got the right set of caregivers, the combination of all those pieces is magical. It creates the energy and the synergy that you need to make a difference in the lives of those patients."
This article appears in the May 2012 issue of HealthLeaders magazine.
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Jim Molpus is the director of the HealthLeaders Exchange.