For two years, a physician-led group of diverse healthcare stakeholders has been plotting to re-engineer healthcare delivery. The Health Care Delivery Policy Program, a forum created by the Kennedy
School of Government of Harvard University, aims to examine the business practices of outside industries and apply them to healthcare.
The research will be used to explore how measures of patient-centered productivity and severity-adjusted outcomes can be better organized around the business development of healthcare services.
"We want to restructure the healthcare delivery system as a market-based service including a whole different set of structural pieces, including oversight," says Jerome Grossman, M.D., director of the Harvard consortium.
A member of the Institute of Medicine since 1983, Grossman served on the quality committee that produced the recent IOM reports "To Err is Human" and "Crossing the Quality Chasm." The goal of his latest endeavor, which brings together healthcare academics, providers, purchasers, public and private payers and consumers, is to build from the IOM reports with investigations and tests of "delivery system clinical trials."
"We've begun to identify charter health systems, like charter schools, to develop demonstrations to test these hypotheses," Grossman says. "Charters serve as a catalyst for change without overhauling the whole system. That is our strategy."
Physicians will support this approach because it is voluntary, Grossman says.
With the 2001 enrollment of its first class, the new College of Medicine at Florida State University in Tallahassee, Fla., a Harvard partner, seized the occasion to develop new care models for a new breed of doctor, says Dean Joseph Scherger, M.D. One of the big shifts playing into medical education is the understanding that the complexity of modern medicine exceeds the limitations of an unaided human mind, Scherger says.
"We can't deliver healthcare off the tops of our heads anymore," he says. "No one is able to deliver the latest best practice. Whether you're a specialist or a generalist, you need knowledge-management tools. We are teaching our medical students from day one that they shouldn't be trying to memorize everything."
Each of Scherger's students is given a fully loaded handheld computer and a wireless laptop, carried at all times to check for clinical guidelines and drug interactions. The students are taking these devices directly into the community as part of standard practice.
Because there is no university hospital or university faculty practice group, all clinical education is through partnerships with existing providers.
One such partnership is a planned undertaking between the medical school and the St. Joe Land Co., which is developing new communities on nearly 1 million acres of land in Florida's panhandle. Working with other local providers, FSU medical students will help put in place new models of supported care based on the IOM reports, Scherger says.
As in Celebration, Disney's planned community near Orlando, Fla., the emphasis will be on patient-centered preventive care, health promotion and fitness.
And just as charter schools are more demanding of family involvement, Grossman says charter health systems will expect more from patients.
"You get a reduction in your health insurance premium if you don't smoke," he points out. "If patients are good compliers, should they not be given some deduction in their insurance? Patients will pay for performance. It is critical to recognize that this is not a one-way street."
Looking at the evolution of the 401(k) is useful in order to understand this shift in how consumers will participate in their healthcare decisions. Last August, Fidelity Employer Services Co. took over administration of the pension and health plans of all of IBM's 150,000 employees and 140,000 retirees in the United States. Even if one changes jobs, he or she would not have to change insurers, because Fidelity would maintain contracts with a large number of insurance companies.
The Harvard group is monitoring this initiative, discussing how it could be a model for stable health insurance management.
"The goal of the IBM/Fidelity trial is to change the way consumers and companies act in moving toward rollover and portability, like a 401(k)," Grossman says. "It is a significantly different strategy for the consumer than co-paying for the benefit, where the company keeps the money and is at risk for the money. It's starting out more as an engineering and business trial than medical only. We'll be there to follow it and they'll be able to bring observations and questions to the group."
For more about the Harvard research, see