Center for Studying Health System Change

umerous efforts underway in the Boston community are intended to influence clinical practice and health care delivery. The major insurers and health plans in the market are all involved, to varying degrees, in quality and utilization management. The systems and approaches developed by health plans were generally described as comprehensive and systematic, and highly collaborative in how they have engaged providers in a positive way as active participants in quality improvement processes.

Respondents cited many examples of quality improvement initiatives, including:

• development of practice guidelines, physician profiling, clinical targets and monitoring systems for high-cost and prevalent diseases and conditions; and

• collaborative work with plans in other geographic regions to benchmark performance in selected clinical areas and to identify and share best practices.

Health plans emphasize the importance of positive incentives to providers, as opposed to punitive measures. Some viewed this choice as evidence of plans’ convictions that physicians are more likely to respond favorably to quality improvement processes that rely on information feedback, guidance from respected clinical leadership and positive reinforcement.

In the case of two plans, Lahey Hitchcock and HPHP, it was also noted that some or all clinical management systems were developed as integral components of a multispecialty group practice environment, and probably reflect the emphasis on group process and peer review that is characteristic of this organizational culture. But others were quick to note that in a market characterized by health insurance products with broad overlapping networks and minimal risk-sharing with providers, health plans may lack the requisite leverage and incentives to influence clinical decision-making processes through mechanisms other than information feedback and education.

As discussed earlier, the AMC-based systems have made considerable progress in acquiring and piecing together the components of a comprehensive care delivery system, and some early signs indicate that they may be positioning themselves to assume more discretion over capitated dollars and care management functions. Partners, in particular, has communicated its intention to negotiate with insurers and health plans for nearly full capitation payment and delegation of credentialing, quality and utilization review functions.

But both Partners and The Care Group face major challenges in integrating and transforming the various internal management and operational processes of the system components to achieve economies of scale, efficiencies and improved care outcomes. There is evidence that this internal restructuring and infrastructure building phase is well underway at The Care Group. The Care Group is devoting considerable resources to the integration of academic programs, clinical services and financial operations of its two major area hospitals, Beth Israel and Deaconess, and to the centralization of key functions (e.g., contracting with health plans, physician billing, administration of management information systems and purchasing and materials management) for the entire six-hospital system.

There is less evidence of reengineering and internal system development among other major provider systems, and it is too early to assess the likely impact of these efforts on patient care.