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Integrating While We Wait

It is exciting to see that many important stakeholders in the healthcare payment and delivery system are already thinking about integration and coordination in the lead up to full implementation of health reform.

However, when pressed on exactly what they want their systems to look like come 2014, the parameters of the relationships with their provider and payer partners, and what needs to done to get there, many are unsure of the details, instead deferring to the federal government for guidance.

In particular, eyes seem to be affixed on CMS who is currently working on regulations that define Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs).

Both Medical Homes and ACOs are referenced and prioritized in the ACA and are seen as key mechanisms to encourage and incentivize hospitals, physicians, clinics, plans and others to move to more integration and “systemness.” But the language in the federal law (on what is and isn’t a PCHM or ACO, for instance) is rather general. Although there have been some preliminary Q&A’s, the regs are expected to offer considerable guidance to states, plans and providers.

While the regs are expected soon, we shouldn’t be simply sitting around and waiting. Regardless of what they contain or where they draw lines, it is imperative that all stakeholders begin in earnest the process of integration, both internally (within their existing system) and externally (in their relationships with others) to reach the shared goals of better outcomes, more transparency and greater efficiency of care.

Within a particular provider group or setting, this might mean a move to electronic health records and greater Health IT, keeping and easily accessing important patient data, and retraining staff. For plans, it’s experimentation with different payment models (pay-for-performance, condition-adjusted capitation, value-based pricing, or the PROMETHEUS system, for instance).

The 1115 Waiver provides opportunities and encouragement for public hospitals, clinics, and managed care plans to move towards systemness: the Delivery System Reform Incentive Pool, moving the SPD population to managed care, and CCS integration pilots. There are other opportunities for creative and integrated alignment within the waiver, especially within the Low Income Health Program, which we’ll discuss in future posts.

But for now, as we await the ACO and Medical Home regs, lets begin to analyze what each of us can do – internally and with others – to better coordinate and integrate. If we do, greater care, lower costs and better outcomes can define the future of California’s healthcare system.

Time is of the essence. Several HHS Agency and Department of Healthcare Services staff are wearing buttons that say “2014 is tomorrow” — in many respects it is.