In the opening session of this year's World Health Care Congress at the Marriott Wardman Park Hotel in Washington, D.C., Robert Pearl, M.D., executive director and CEO of The Permanente Medical Group and president and CEO of the Mid-Atlantic Permanente Medical Group, was part of an in-depth panel discussion on the elements of the healthcare system that are not working and how they can be fixed.
A key focus from Dr. Pearl, author of the just-published book Mistreated: Why We Think We’re Getting Good Health Care—And Why We’re Usually Wrong, during the keynote session, was how healthcare needs to become more integrated. He said, per Editor-in Chief Mark Hagland's report, "If you integrate care, horizontally among physicians and vertically among the pieces of the continuum of care, all of a sudden, the physicians start to coordinate and collaborate, and you get the results you need. As soon as you capitate, all of a sudden, prevention, and early care become more significant, and you can see the care gaps."
Indeed, integration is a key point of emphasis for Kaiser, headquartered in Northern California and composed of the Permanente Medical Groups, Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals. The specific organizations that Pearl directs are comprised of over 9,000 physicians and 34,000 staff members, and he is responsible for the healthcare that is delivered to more than 4 million Kaiser Permanente members in the states of California, Virginia, Maryland and the District of Columbia. After his morning panel discussion, Pearl caught up with Healthcare Informatics Managing Editor Rajiv Leventhal at the conference to talk about integrated care, health policy, health IT's role, and more. Below are excerpts of that discussion.
Tell me a little bit about what's new with The Permanente Medical Group and how it continues to evolve.
Kaiser Permanente provides care to 12 million Americans in eight different states. The biggest technology evolution we have seen has been a rapid increase in telehealth, but that's a term that's utilized in a traditional medical way. To me, "video" is like saying computer and telephone; it's a foundation. How you use it is dependent upon the care delivery system in which you work. In [my book] Mistreated, my observation is that context sets perception, which sets behavior. And that if you you take a tool like telehealth and put it into the a fragmented fee-for-service world, all you see is a lot of communication, but not value created as a result. If you don't have an EHR [electronic health record] underlying it, you can't get comprehensive information, and if you don't have an EHR to enter data into, the next person doesn't know what you did. As soon as you're in that integrated context, that's were you get the power. People now in the right context have the right perception, so how can we use this? How do I provide care at a long distance that's convenient for you and how do I reach out some place and bring expertise? Those are the questions you begin to ask as long as you're in the right context.
Can you give an example of how this might look in the real world?
Looking at vertical integration, you have a primary care physician and a specialist working together as one, so if you're seeing a primary care physician and he or she needs specialist expertise, why send a consult rather than immediately link primary care and speciality care? If you're in a fragmented world of care delivery, it's hard to do this since all the doctors are already seeing [their own] patients. But as soon as you have become an integrated care delivery system, that [changes]. I am also the chairman of the Council of Accountable Physician Practices [CAPP], and in these large multi-speciality medical groups, you can assign a doctor to be available on video who has an EHR, and that starts to change the entire set of dynamics where you can lower costs today and higher quality is a consequence.
How do you feel about healthcare policy right now, in the current moment? When you look at the value-based care road that the industry is on, are you happy with where things are going?
No, that's why I wrote the book Mistreated. I believe the focus has been on MIPS and MACRA, and not that they're bad things, but they are too little and too slow. I see four pillars to what needs to be the evolution: care has to be fully integrated, vertically and horizontally; care has to be capitated so everyone has the right incentive to do the right thing the first time; there should be focus on prevention of medical errors, so [healthcare] must be technology-enabled, via EHRs, mobile and video; and it has to be physician-led. You need all of those pillars and without them, change will be slow and the nation will become a two-tier system of medicine before it evolves into a high-performing one.
It takes all of these pieces together, and capitation is an essential pillar, but if you all you do is capitate a large number of physicians and there's no leadership to be able to structure it in a way so you have the right physicians in the right specialities at the right time, that's not [good enough]. In my book I talk a lot about the need for more primary care and less speciality care, and how specialists will have primary volumes with better quality outcomes as a consequence of that. The technology is remarkably powerful, but it's in a context with integration, with capitation, and with physician leadership.
Kaiser has obviously set the pace in terms of how they're doing integrated care. Can this be replicable and scalable for other institutions and what lessons have you learned with this model?
It's definitely scalable and replicable. So Kaiser Permanente is really three organizations; there is a health plan, the hospitals, and the Permanente Medical Group. They are three coming together as equals. The challenge is that putting together that type of integrated system is difficult. You have to make sure you rightsize your specialities and your number of hospitals, and you need to make sure that you change how you reimburse physicians, with a a need to focus on prevention. So there are a lot of pieces that need to come together and that's the challenge. It's easier to do more in medicine than to do better. That's a problem right now.
With new federal health leaders placing an emphasis on having health IT make life better for doctors, what impact do you see this having down the road?
We talk about health IT and computers as if it's all the same. It's not at all, though; the machines are the same but the processes are different. I think about it in three phases: the first phase is the doctor sitting in office entering information on the computer, and it's better than handwriting since it's more legible, but the experience has been that it slows them down rather than adding value. It just takes more time entering something electronically. The second level is interoperability. We are failing to understand there that if I have to go into your record and other records to get information of a patient, that's a lot of time [taken up] and is very inefficient. What's needed is a comprehensive EHR where all of the information is available and presented to me as the treating doctor. If this were the case, even though I might be an ophthalmologist, I would know that you haven't had your colon cancer screening done, so I can take the action to accomplish it. I never would have asked you about it, but when it's right in front of me I can.
For this to happen, you have to open up the APIs [application program interfaces] and the third-party developers can then come in and extract the data out of the systems and do what's been happening for ATMs—meaning you can go to any machine anywhere in the world and get the money out or deposit money into it, no matter the bank you have. But getting the big vendors to open the APIs will be quite the political challenge.
A few years ago Kaiser made big news with its $4 billion investment to go digital. What lessons have been learned since that time?
Well we have a fully comprehensive EHR, both for outpatient and inpatient. I joke about wanting to start a museum at Kaiser because all of the people we now train have seen a paper record or a true X-ray or a lab slip, so they wouldn't know what they would look like. If you look at the National Committee for Quality Assurance [NCQA] ,there are a a thousand programs, and we're No. 1 in the entire country. [The NCQA annual report rates more than 1,000 health plans on quality including Medicare, Medicaid, and commercial on a 0-5 scale with 5 being the best, and Kaiser had 8 of the 23 health plans that were given a 5 out of 5 in 2016]. Why is that? The [comprehensive] EHR first and foremost—without it we never would have accomplished all of this.
We are able to provide care through almost as many virtual visits as in-person visits. You couldn't do that without the comprehensive set of information. We have a stroke neurologist who is actually available to see the patients the minute they walk through the door, and our door-to-needle time to get the clot-busting drugs is now under 30 minutes, while the rest of the nation is over a year. Four months ago I broke my leg and I went to the local Kaiser facility and the physician there said that there is a doctor who's really good at your operations, located 15 miles away. But then he said, "Let me just link you up with video." Imagine if I needed an ambulance in both directions, and the pain that would come with that. We also look at a lot of patient satisfaction data; we survey over 1 million patients a year and that [revealed] that the satisfaction for a video visit is higher than an in-person visit.
Finally, what are one or two important takeaways that you would like people to know about your book?
The first big takeaway is that the legacy players—the big insurance companies, the pharmaceutical companies and the physician speciality groups—will not change since they like the current system too much. A lot of the book is written for patients, not policymakers or physicians. Also, I'd like people to know that any profits will be given to charity. I have spent my entire career committed to transforming American medicine—some of it by how it's structured and a lot of it by technology. I have been the CEO here for 18 years and we have been at the forefront of first implementing EHRs; then we were at the forefront of secure email a decade ago; and after that, we are the the No. 1 provider of video visits in the U.S. So we're always staying at the cutting edge of technology. Bringing together hi-tech and high-touch is key, so the technology outside of the personal; because if in the process of creating the scientific improvement in healthcare we lose the personal and the compassion, we will have lost as part of the bargain.