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Alain C. Enthoven and Laura A. Tollen, Competition In Health Care: It Takes Systems To Pursue Quality And Efficiency, Health Affairs Web Exclusive, September 7, 2005 [Abstract] [PDF] [HTML Version] [Reprints & Permissions]

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Innovations in Systemness

Mark C. Shields   ( 16 September 2005 )

Innovations in Systemness 16 September 2005
Mark C. Shields, Senior Medical Director Advocate Health Partners Send comment to journal: Re: Innovations in Systemness mark.shields-md{at}advocatehealth.com Mark C. Shields	While I agree with your call for competition at the system level, I fear you have not given enough attention to the innovations in developing systemness. These innovations indicate entrepreneurialism, a sign of a healthy market. You cite considerable evidence of the advantages of prepaid group practice systems (the prototype of your IDS model). Despite this evidence, such models continue to serve a minority of the U.S. population, especially outside of California. Instead, over half the doctors in the U.S. practice in groups of 3 or fewer physicians (American Medical Association, 2001 Patient Care Physician Survey). Newer models are needed to accomplish the advantages of organizations like Kaiser while meeting the market-driven desire for care from small practices. As you point out, the key is “how one defines a network.” For over a decade, Advocate Health Partners has provided a progressively increasing amount of systemness across 2,700 doctors and the 8 Advocate Health Care hospitals in the Chicago metropolitan area. Two thousand one hundred of these doctors are in private practice, mostly in groups of 4 or fewer doctors. The other 600 doctors are in large multispecialty groups owned by Advocate Health Care. Starting out with risk (HMO) contracts, this physician-hospital organization (PHO) has expanded its programs to include PPO (fee-for-service) products. Advocate Health Partners has continuously expanded its Clinical Integration program through provider credentialing, clinical protocols, disease registries, shared computerized systems, performance report cards fed back to providers, external reporting to employers and managed care organizations, financial incentive systems for doctors and hospitals (pay for performance), and joint contracting across providers for both risk and fee-for-service programs. We now contract with all but one major carrier in Chicago for these clinically integrated services. In our market, as in most across the country, prepayment has been dwindling as a method to pay providers. In fact, currently, of the approximately 1 million patients served by Advocate Health Partners, only about one-third are in prepayment (risk) programs. For “systemness” to emerge in the current marketplace, such systems need to be able to grow and demonstrate value in a fee-for-service setting. In your article you touch on the “evolution toward systemness.” It is important that academics, regulators, and insurance companies encourage this evolution and not fix on a single model, no matter how effective it has been in its local setting.