Michael Porter thinks that the management of delivery has to catch up to the science of medical care

His fundamental starting point is to stop thinking about specialties & functions and start thinking about delivery around medical conditions—an interrelated set of circumstances, best addressed in an integrated way—around the cycle of care. Differences between in-patient/outpatient, acute/chronic/rehab are all irrelevant.

Where we need to go is an integrated practice model that focuses on the patient condition and is centered around the patient needs. This restructuring of the system is vital.

But for now, competition is zero sum & cost shifting. Need to compete on value for the patient, and get paid for improving that. The most important driver is measuring results.We’re measuring process but not measuring outcomes. And that needs to be measured at a medical condition level, and he presents a level of outcomes (starting with survival and getting better from there) that can be managed. Adding IT is necessary

Government policy will set the rules of the game but will not restructure it. He thinks that government, payer or consumer can’t lead this. Only physicians can do it. He thinks it’ll be the most empowering thing for physicians. But he admits that they’ve been resistant.

He thinks that employers should be kept in the system—he thinks they are innovating and improving in providing insurance. We need to create risk pools and structure, and an individual mandate.

He thinks the biggest criticism of his view is not feasible—but it’s already happening with employers, health plans being transparent.

Matthew’s comment: How has his thinking changed? Not too much. He’s started talking about different condition centers coordinating for multiple co-morbidities, which is a slide towards the integrated system model. Of course we’ll find out whether that works in practice, but it hasn’t happened in integrated systems with aligned incentives thus far. But this time (unlike in 2005 when he spoke for 90 minutes) he spoke for 15 minutes and did get to incentives in terms But he thinks things are moving now. They’re not—what he calls movement is a a blip. And without starting with government policy change, we’re never going to get to a real system that has the right incentive. Why does the light bulb want to change?

Ron Williams, Aetna: uninsurance is a big problem, and employers mostly want to stay in the game of providing health insurance. But we have to recognize that we (insurer) need to help. The consumer has a key role, but that conversation defaults to the HSA. But they need lots lots more to help them and we have to create those tools—but when someone is really ill being a good consumer is to understand quality of care, and get them to high quality institutions? Our challenge is picking up 700K docs and 5500 hospitals and moving them to where they need to go.

George Halvorson, Kaiser Permanente: How do we get there? We need two channels. One for acute care, one for chronic.Can do a pricing model for acute, but the big dollars are in chronic care. That needs electronic connectivity and infrastructure to make it happen. Someone has to make that happen. The major payers (including government) can make that happen. If we don’t go down that path we’re going to have inefficient care.

John Iglehart asks—what would force providers to change their care delivery model?

Porter: The only way is to measure results make physicians accountable to outcomes, and then the providers will change.

Williams: Have to make delivering the right care a cost effective business decisions—we have to create a win-win between

Porter: We have fragmented incentives, need to change the pricing model. Need to be concerned about the provider who goes broke because he sees fewer office visits.

Halvorson: We need choice and info around acute care (knee surgery) and we need an infrastructure for team care around chronic care. Trying to do both in the same market place doesn’t make sense. The only way to spread this is sytemness (electronically).

Williams: We are the center of that information infrastructure

Iglehart: Are you getting optimistic?

Porter: Getting more optimistic everyday. What’s different today than 10 years ago is that everyone believes that we have to do this differently? “It would be great if public policy helped” (getting rid of Stark laws, corporate practice of medicine laws) “but I think this is going to happen anyway because it’s in the self interest of employers, providers, consumers, health plans to do this because they all care about value”

Iglehart: Do you need employers?

Porter: In principle no, but many employers are caring about the value of their employers health but we should hang on to them. But we have to make individual insurance market at least equal.