Physician-led models of accountability and value: observations on payment policy and culture.

IN 1910, CHARLES H. Mayo, MD, observed that the previous 50 years had been marked by advances in the science of medicine and that the next 50 years would be marked by advances in the organization and coordination of healthcare delivery (paraphrased from the 1910 commencement address to Rush Medical College). Today, more than a hundred years later, Dr. Mayo might well be disappointed to see the level of fragmentation remaining in US health- care. But there is hope. As Molden, Brown, and Griffith report regarding Pied- mont Healthcare (PHC) and Leaver describes for UnityPoint Health, when in- tegrated and coordinated care is a priority, value can be significantly improved.Molden, Brown, and Griffith describe how a partnership between three cardiovascular physician practices and PHC successfully evolved into the fully integrated, physician-run entity Piedmont Heart. That example of single-silo integration can be compared to Leaver's summary of UnityPoint Health's broad effort to coordinate patient care across silos, including its experience as a pio- neer accountable care organization (ACO) and its participation in the Medi- care Shared Savings Program (MSSP) pilot. Both feature articles emphasize the importance of physician leadership and attention to metrics or benchmark targets, though neither identifies specific measures.PIEDMONT HEARTA skeptic might see the development of Piedmont Heart as the fulfillment of cardiovascular physicians' wish to preserve income and PHC's desire to drive volume. Be that as it may, Piedmont Heart's centers-of-excellence design, trunk-and-branch approach to clinical pathways, and Patient First program demonstrate its commitment to patient-centered care and ability to address highly complex medical, logistic, and cultural issues.While the infrastructure being developed at Piedmont Heart is impressive, the organization's progress over the next five years will be interesting to track. The following are among the key questions that need to be answered:* How will quality and safety metrics compare to benchmarks?* How will cost per episode of cardiovascular care compare to benchmarks?* Will population health results be measured and reported with good metrics for quality measures, annual cost of care, and admission and readmission rates?* Will bundling pilots be launched with Medicare, commercial payers, or both?* Will Piedmont Heart and PHC budgets be integrated in a way that yields reliable cost measures and comparisons?* How well will the care of patients with multiple diseases be coordinated with other specialties and clinics?* Will real-time decision support analytics help sustain improvement activities?* Will clinical pathway diffusion greatly improve standardization where appropriate, and will the quality and cost measures show definitively improved value?UNITY POINT HEALTHUnityPoint Health is developing a broad approach to coordinating care. Its efforts to develop physician leadership; focus on complex, high-cost patient populations; initiate the advanced medical team model; implement the nurse call system; focus on emergency room visits; use home care; and develop a single information technology platform are extremely promising initiatives. In addition, the system's early participation in an ACO and the related MS SP helped it to pursue the goal of merging data from insurance claims with its clinical database. The additional data enable clinicians to see how silos affect patient care and clearly illustrate how a patient progresses through the system of care and how chronic disease is managed.Many questions about UnityPoint Health will be answered over the next five years. They include the following:* How will physician relationships evolve across UnityPoint Health's many sites?* Will the system's data analytics reduce variation in quality and cost?* Will the physician leadership program improve the performance and continuity of physician leadership? …