Frank deGruy, MD, MSFMChicago, IL

June 22, 2011

From the Vantage of Primary Care The Nature of the Fragmentation The Range of Integrated Solutions The Fundamental Policy Problem How to Work Together

Clinical Integration Vertical Integration

Population served Diversity of patients

By problems By payer

Diversity of practice forms Press of practice & competing demands PCMH & team-based care External collaborations

For PCPs with single or simple payer mixes

For “private” practices Consultations and referrals according to

matrix Upgrade in-house resources IPA-type solutions Other

Fast success, fast failure

Guidelines Implementation Sustainability

What do we pay for? Office visits Procedures For only some problems

What should we pay for? Health! Health care

Collaboration, integration Innovation

Measure health, healthcare, and cost outcomes

Pay for good health—within limits Pay for quality care Pay patients for participating Pay for partners to practice together Stop paying for bad care

That is fragmented & redundant Stop paying for too much care

Health Plans are architects: try new designs

Clinical integration Professional culture & practice style Communication Team-based care Operating principles adopted by ICSI

Independence of thought Diversity of opinion Decentralization of authority Ability to aggregate & share learnings

Vertical integration The role of the convener Adaptive vs. technical problem Solutions for complex problems & Theory U

• Loose connections

• Mapping (linking)

• Passion

• Emotional intelligence

• Trust in process

• Inspiration

• Tolerance of ambiguity

• Hands off approach

• Receding

• Backing away as work advances

Adapted from “The Starfish and the Spider”(Ori Brafman)

And--pointing at the “pole star”

Adaptive Challenge is complex Need to address & change deeply held beliefs &

values Loss is an inherent part of process Can’t be achieved within present system—people

must acquire new capabilities

Technical Problem is well defined Answer can be found within present system—

requires application of abilities already in it Implementation is clear

C. Otto Scharmer (2007); Theory UThanks to Gary Oftedahl for the Theory U diagram

A new group wants to jump to solutions

But a wise convener leads them through the U

To a realistic shared solution

Productive Range

Threshold of learning

Limit of tolerance

Time

Ten

sion

of

chan

geProductive levels of distress

in human systems

Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

Productive Range

Threshold of learning

Limit of tolerance

Technical challenge

Time

Technical vs. Adaptive WorkAdaptive Challenge

Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

Ten

sion

of

chan

ge

Keep in mindthe social geographyof your project!