In the opening session of this year's World Health Care Congress at the Marriott Wardman Park Hotel in Washington, D.C., Robert Pearl, M.D., executive director and CEO of The Permanente Medical Group and president and CEO of the Mid-Atlantic Permanente Medical Group, was part of an in-depth panel discussion on the elements of the healthcare system that are not working and how they can be fixed.
A key focus from Dr. Pearl, author of the just-published book Mistreated: Why We Think We’re Getting Good Health Care—And Why We’re Usually Wrong
, during the keynote session, was how healthcare needs to become more integrated. He said, per Editor-in Chief Mark Hagland's report
, "If you integrate care, horizontally among physicians and vertically among the pieces of the continuum of care, all of a sudden, the physicians start to coordinate and collaborate, and you get the results you need. As soon as you capitate, all of a sudden, prevention, and early care become more significant, and you can see the care gaps."
Indeed, integration is a key point of emphasis for Kaiser, headquartered in Northern California and composed of the Permanente Medical Groups, Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals. The specific organizations that Pearl directs are comprised of over 9,000 physicians and 34,000 staff members, and he is responsible for the healthcare that is delivered to more than 4 million Kaiser Permanente members in the states of California, Virginia, Maryland and the District of Columbia. After his morning panel discussion, Pearl caught up with Healthcare Informatics Managing Editor Rajiv Leventhal at the conference to talk about integrated care, health policy, health IT's role, and more. Below are excerpts of that discussion.
Tell me a little bit about what's new with The Permanente Medical Group and how it continues to evolve.
Kaiser Permanente provides care to 12 million Americans in eight different states. The biggest technology evolution we have seen has been a rapid increase in telehealth, but that's a term that's utilized in a traditional medical way. To me, "video" is like saying computer and telephone; it's a foundation. How you use it is dependent upon the care delivery system in which you work. In [my book] Mistreated, my observation is that context sets perception, which sets behavior. And that if you you take a tool like telehealth and put it into the a fragmented fee-for-service world, all you see is a lot of communication, but not value created as a result. If you don't have an EHR [electronic health record] underlying it, you can't get comprehensive information, and if you don't have an EHR to enter data into, the next person doesn't know what you did. As soon as you're in that integrated context, that's were you get the power. People now in the right context have the right perception, so how can we use this? How do I provide care at a long distance that's convenient for you and how do I reach out some place and bring expertise? Those are the questions you begin to ask as long as you're in the right context.
Can you give an example of how this might look in the real world?
Looking at vertical integration, you have a primary care physician and a specialist working together as one, so if you're seeing a primary care physician and he or she needs specialist expertise, why send a consult rather than immediately link primary care and speciality care? If you're in a fragmented world of care delivery, it's hard to do this since all the doctors are already seeing [their own] patients. But as soon as you have become an integrated care delivery system, that [changes]. I am also the chairman of the Council of Accountable Physician Practices [CAPP], and in these large multi-speciality medical groups, you can assign a doctor to be available on video who has an EHR, and that starts to change the entire set of dynamics where you can lower costs today and higher quality is a consequence.
How do you feel about healthcare policy right now, in the current moment? When you look at the value-based care road that the industry is on, are you happy with where things are going?
No, that's why I wrote the book Mistreated. I believe the focus has been on MIPS and MACRA, and not that they're bad things, but they are too little and too slow. I see four pillars to what needs to be the evolution: care has to be fully integrated, vertically and horizontally; care has to be capitated so everyone has the right incentive to do the right thing the first time; there should be focus on prevention of medical errors, so [healthcare] must be technology-enabled, via EHRs, mobile and video; and it has to be physician-led. You need all of those pillars and without them, change will be slow and the nation will become a two-tier system of medicine before it evolves into a high-performing one.
It takes all of these pieces together, and capitation is an essential pillar, but if you all you do is capitate a large number of physicians and there's no leadership to be able to structure it in a way so you have the right physicians in the right specialities at the right time, that's not [good enough]. In my book I talk a lot about the need for more primary care and less speciality care, and how specialists will have primary volumes with better quality outcomes as a consequence of that.