Achieving Bidirectional Integration A Policy Summit Frank deGruy, MD, MSFM Chicago, IL June 22, 2011

Executive Summary From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

Outline From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

From the Vantage of Primary Care Population served Diversity of patients By problems By payer Diversity of practice forms Press of practice & competing demands PCMH & team-based care External collaborations

Outline From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

The Nature of the Fragmentation Diseases vs. people Mind from body Patients from clinicians Clinicians from communities Generalists from specialists Patients and clinicians from purchasers from payers from policymakers

Outline From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

The Range of Integrated Solutions For PCPs with single or simple payer mixes For “private” practices Consultations and referrals according to matrix Upgrade in-house resources IPA-type solutions Other Fast success, fast failure

The Natural History of a Guidelines Shop Implementation Sustainability

Outline From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

The Fundamental Policy Problem What do we pay for? Office visits Procedures For only some problems What should we pay for? Health! Health care Collaboration, integration Innovation

All Roads to Sustainability Run Through Payment Reform Measure health, healthcare, and cost outcomes Pay for good health—within limits Pay for quality care Pay patients for participating Pay for partners to practice together Stop paying for bad care That is fragmented & redundant Stop paying for too much care Health Plans are architects: try new designs

Outline From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

How To Work Together Clinical integration Professional culture & practice style Communication Team-based care Operating principles adopted by ICSI Independence of thought Diversity of opinion Decentralization of authority Ability to aggregate & share learnings

Outline From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together Clinical Integration Vertical Integration

How To Work Together Vertical integration The role of the convener Adaptive vs. technical problem Solutions for complex problems & Theory U

Convener As Catalyst • Loose connections • Inspiration • Mapping (linking) • Passion • Emotional intelligence • Trust in process • Inspiration • Tolerance of ambiguity • Hands off approach • Receding • Backing away as work advances Adapted from “The Starfish and the Spider” (Ori Brafman) And--pointing at the “pole star”

Adaptive vs. Technical (R. Heifetz-”Leadership without easy answers”) Challenge is complex Need to address & change deeply held beliefs & values Loss is an inherent part of process Can’t be achieved within present system—people must acquire new capabilities Technical Problem is well defined Answer can be found within present system—requires application of abilities already in it Implementation is clear

But a wise convener leads them through the U A new group wants to jump to solutions To a realistic shared solution But a wise convener leads them through the U C. Otto Scharmer (2007); Theory U Thanks to Gary Oftedahl for the Theory U diagram

Productive levels of distress in human systems Limit of tolerance Productive Range Tension of change Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108. 20

Technical vs. Adaptive Work Adaptive Challenge Limit of tolerance Tension of change Productive Range Threshold of learning Technical challenge Time Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108. 21

Keep in mind the social geography of your project!