“Making the right things easier to do”. Evidence based management supports integrated care in Kaiser Permanente – Reply to editorial Guus Schrijvers December 2007
International Journal of Integrated Care, 27 February 2008 - ISSN 1568-4156
Commentary
“Making the right things easier to do”. Evidence based management supports integrated care in Kaiser Permanente – Reply to editorial Guus Schrijvers December 2007

The interesting and informative editorial by Schrijvers inspired by a study visit in fall 2007 to Kaiser Permanente Northern California (KPNC) discusses how external competition may support the integration of care in KP and how the achievements of KPNC potentially can be transferred to benefit European healthcare systems.

As participants on the same study visit to KPNC and visiting researchers at the Division of Research, The Permanente Medical Group, we recognize the complexity of the issue and would like to add an additional perspective that might help to explain the integrated care achievements of KPNC.

First and foremost, KP's history of being a supporting facility for an industrial production line seems to play an essential role in the way that the system has developed into an integrated delivery system. From the beginning, the KP system focused on keeping the insured workers healthy and treating their symptoms to prevent illness. KP became a self contained delivery system with its own full-time doctors, nurses and staff, based on a prepaid, fixed budget model. KP still recruits clinicians who value prevention, a whole systems approach to health care, and who embrace team based treatment [1], all important factors in building an environment for integrated care delivery. While health prevention and health promotion have historically been separated from the care delivery system in most other US and European health care systems [2], the KPNC health care delivery system has integrated these from the start.

Another important factor contributing to integrated care delivery in KPNC is the organisation of the system with three separate but interdependent groups of entities (the Kaiser Foundation Health Plan, the Permanente Medical Groups, and the Kaiser Foundation Hospital), each with clear roles and responsibilities and a hierarchical management structure. In many European health systems, the responsibility for financing and provision of care is dispersed between multiple units and professionals in network-type organisations, without a clear hierarchical management structure, which turns the integration of care into a challenge. The responsibility of non-hospitalised care is decentralised to the physician-led management at the medical centres, covering the entire production line from health prevention and promotion activities to highly specialised outpatient care [1]. This system allows management of patients in the most appropriate setting from a clinicians viewpoint and allows trade-offs in expenditures based on appropriateness and cost effectiveness rather than on artificial budget categories linked to specific sub-organisations [1]. Additionally, the physician-led management allows for combining knowledge from evidence based medicine and evidence based management. This combination contributes to keep the focus on improving the quality of care guided by the evidence [3, 4]. The medical centre structure also permits implementation of comprehensive and compatible information communication technologies (ICT). The electronic health record supports clinical decision-making and facilitates integrated care by making it easier to transfer information among healthcare providers and between patients and their health care providers [5].

We support the view by Schrijvers that external competition to a great extent is the driver for how KPNC is managed, structured and organised and as such has an (indirect) impact on the provision of integrated care in KP. However, most other American care management organisations do not provide integrated care to their members to the same extent as we see in KP [6]. We believe that factors such as the history of Kaiser, the whole system approach to care among KPNC employees, the physician-led management emphasising the use of EBMgt, and the willingness to make long-term investments in IT are essential and must be taken into account when comparing KPNC with European health care systems. These factors seem to facilitate the provision of integrated care in KPNC. However, to direct policy efforts and guide health system planners in potential reorganisation of European health systems, we need to strengthen the evidence base by conducting detailed research comparing KPNC and like systems with a broader spectrum of European health care systems. We hope that the International Journal of Integrated Care will support this type of research and continue this important debate.

Michaela L. Schiøtz PhD Fellow, MSc Public Health, Department of Health Services Research, Institute of Public Health, Faculty of Health Sciences, University of Copenhagen

Martin Strandberg-Larsen PhD Fellow, MSc Public Health, Department of Health Services Research, Institute of Public Health, Faculty of Health Sciences, University of Copenhagen

References
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Light D, Dixon M. Making the NHS more like Kaiser Permanente. British Medical Journal 2004 Mar 27; 328(7442):763-5.
2.
Porter D, editor. The History of public health and the modern state. Amsterdam – Atlanta, GA: Clio Media; 1994.
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Shortell SM, Rundall TG, Hsu J. Improving patient care by linking evidence-based medicine and evidence-based management. JAMA: the Journal of the American Medical Association 2007 Aug 8; 298(6):673-6.
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Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. The Milbank Quarterly 2001; 79(3):429-57.
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Strandberg-Larsen M, Schiøtz M, Frølich A. Kaiser Permanente revisited – Can European health care systems learn?. Eurohealth 2008; 13(4). (in press).
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American College of Physicians. Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Annals of Internal Medicine 2008 Jan 1; 148(1):55-75.