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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. The Natural History of a Guidelines Shop
Implementation
Sustainability

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. 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”

18. 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

19. 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

20. 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

21. 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

22. Keep in mind the social geography of your project!