Bottom-line, it was not well written from an editors viewpoint and the book further complicated an “industy” that is already complicated. I had hoped for some vision in the book….and did not find it….just more confusion, albeit that is the basic problem.

Our healthcare “system” has merely become too complicated to be successful. There is a solution…..but not traditional…and perhaps our international colleagues will be leading the charge in how to better address the pending crisis in chronic disease management. In the US we are “playing with the boxes” and “throwing out the toys.”

I hope this paper trail can help get to a higher level.

Independent, specialized IPUs make a lot of sense in some special circumstances (not all, Professor Herzlinger, just some), but whats to prevent serious conflicts between the condition-specific treatment plans for the comorbid patient with HF, CAD, COPD, and CKD in the absence of a unifying or integrating primary care entity a medical home, indeed? The described segmentation of specialized care might be not only be inconvenient but potentially lethal for these complex patients, as the expertise for treating different conditions simultaneously may be missing or at least diminished in such a system.

Sure, we are all eager for faster EMR adoption, but mere availability of an integrated EMR is insufficient to mitigate this threat. PT conveniently stipulate that primary care would become its own medical condition and would function in primary care IPUs in similar fashion to HF IPUs, ESRD IPUs, etc. But elsewhere they extol the need for expert diagnosis to reside within these specialized condition-specific units, and I foresee serious practical issues with getting undiagnosed patients to the right unit for proper diagnosis unless there is an upstream primary care process that does a lot of preliminary diagnosis or triage and appropriate referral to individual IPUs. Real patients are messy, disorganized, organic beings whose health care needs are very hard to fit into a pristine model of primary care delivery, no matter how glossy its philosophic patina, how articulate the recitation of its basic principles, or how impressive the pedigree of its esteemed architects.

That said, PT’s thesis is not without merit. They are dead on identifying many ways in which the current health care system fails to support value creation. Results focus for defining value for specified medical conditions across span of care is a worthwhile (but hardly novel) suggestion; however, their denigration of process measures as inadequate to the task of value competition, with simultaneous positing of outcomes measures as necessary and sufficient to the task is naive in my view. Most QI experts of the past 2-3 decades who have been working in real organizations with real data and real providers have concluded that there are too few suitable, untainted outcomes measures to do the job of measuring health care at an appropriate level of granularity across the entire spectrum of care a combination of outcomes and process measures are needed to do this job. Even then, this is very hard work to do well, and exceedingly challenging to do at all at the practitioner level.

As always, the devil is in the details, and PT appear to want to stay at the 30,000 foot level where details are moot. To wit:

1. Multiply comorbid patients do not fit their model well, since it seems to assume that discrete medical conditions occur separately and independently; despite the glib assertion that comorbidity management will fall within the expertise of these specialized IPUs, I think that is an unwarranted assumption based on the realities of specialty medicine as we know it today.

2. Primary care IPUs may or may not perform the medical home function that has been recently postulated by others (ACP, AAFP) as the next needed evolution for health care reform. Elsewhere on this blog I have commented on the far greater challenge for primary care to escape extinction in the next decade.

3. The concept of most care rendered by independent, specialized provider units overlooks the fundamentals of primary care from several other perspectives patients preference for having care integration through a single individual or team of clinicians, integration of care for multiple conditions, risk identification and management for multiple conditions, treatment integration across multiple conditions, etc.

4. Prevention is glossed over as a uniform good without a careful distinction between cost-beneficial (i.e., cost saving) programs and cost-effective programs (i.e.,cost that yields adequate return in health outcomes or QALYs)

5. Measuring results over the span of care for medical conditions has conceptual appeal, but may be difficult from practical perspective; if that span is 2-3 years for some conditions, 3-5 for others, how does one decide on the appropriate economic exchanges that should be transacted in the meantime? Care can’t be wholly funded with a balloon payment on the back end of a 3 or 5 year process, so I assume some interim scheme would be needed to approximate the expected outcome, with true-up after the fact. This will become a very difficult negotiation.

6. Gain sharing with providers is encouraged based on value creation as measured by results over span of care for medical conditions; there are many devils in those details that seem reminiscent of zero-sum competition, since total gains less total investments become the fixed pie for dividing among the contributing stakeholders. I am somewhat surprised that PT do not extend the gain sharing concept to include the patients, as well who, more than they, need an incentive to improve adherence to virtuous lifestyle behaviors and adherence to treatment plans?

7. Transparency is also a laudable objective, but despite offering relevant health care quality information to a demanding public for the past decade, I am still uncertain about the degree to which they can understand or use that data. The ESRI Report on Report Cards, issued in 1998, observed that while most consumers say they want report cards, when presented with them, they don’t appear to be willing or able to use them for health care decisions. I trend to agree with the ESRI conclusion: Simply informing consumers (that is, making information available to them) is not the same as informed consumerism, whereby consumers understand and use the information provided to choose health plans and providers and to demand accountability. To foster the latter, employers face technical challenges, educational challenges, and socio-psychological challenges which are daunting. In the 9 years since, have we made much progress in the sophistication of the public in accessing, interpreting, and using quality data?

PT have made a valuable contribution to the extent they are provoking discussion and debate about health care reform, and the many thorny challenges we face with the organization, incentives, transparency, measurement and reporting, provider types and distribution, longitudinal coordination of care, and continuity of health care delivery. Whether their substantive ideas will represent a lasting contribution or not is hard to tell at this point, but they fall short of a complete or practical prescription for what ails health care today. My suspicion is that a far less elegant, and more complex, messy set of pluralistic partial solutions may be the next best step that our society can take in this direction, given political constraints, competing interests, system inertia, and deep public ambivalence. At last report, it is still the case that the average citizen regards U.S. health care as sick, or perhaps even in crisis, but ask about your personal health care and you hear it is viewed as satisfactory, in general – and woe be unto him/her who would render it asunder in the 2008 elections!