Learning about Clinical Commissioning from the USA

by Philip Boxer

The following suggestions are quoted from the views of Lawrence P. Castalino on GP Commissioning in the NHS in England, based on the experience in the USA on GP commissioning.  The page references are to his report.  The comments on the right concern the actions that follow, and relate back to earlier material on asymmetric leadership and asymmetric design.

Suggestion Comment
Suggestion 1. GP commissioning consortia and NHS policy-makers should seek to learn from US independent practice associations (IPAs), not just from US integrated delivery systems (IDSs) 

  • As the NHS prepares to transfer responsibility for commissioning health services to groups of GPs acting together as commissioning consortia, there are important lessons to be learned, particularly from the experience of IPAs in the US. IPAs are networks of independent physicians who come together to hold a budget from insurance companies, but maintain their status as independent businesses. GP consortia will be much more like IPAs than like the IDSs with which the NHS has been more familiar, such as Kaiser Permanente. Page 19
Alignment has to occur horizontally across the NHS ecosystem, not just within a single sovereign enterprise.
Suggestion 2. To succeed, GP consortia will have to invest heavily in leadership, management and infrastructure. 

  • Within the past two decades, the great majority of US IPAs and medical groups failed at risk contracting, including a number of high-profile bankruptcies that disrupted care and cost health insurance plans many millions of dollars. The failures occurred because most IPAs were loosely structured organisations that lacked strong physician leadership, drastically under-invested in management and infrastructure, and failed to gain physicians’ cooperation. To succeed, GP consortia will have to invest heavily in leadership, management and infrastructure. Left to themselves, most GP consortia are likely to under-invest in these capabilities. In the early years, the NHS should provide GP commissioning consortia with generous, ring-fenced budgets to invest in leadership, management and infrastructure. Page 19
Without balance across all of the following four (N-E-W-S), the consortia will fail: 

  • Leadership (N),
  • Strategy driven at the edge by the need to manage the patient’s condition through-its-life (E),
  • Accountable know-how (W), and
  • Agile service delivery systems (S)
Suggestion 3. Provide training for GP leaders 

  • Highly skilled, full-time non-physician managers will be necessary for consortia, but not sufficient – skilled clinical leaders who spend most of their time on consortium activities will be required as well. The experience of successful IPAs in the US suggests that a consortium with 100,000 patients will need at least two physicians who spend the great majority of their time leading the consortium. Contracting with external organisations is likely to be helpful for GP consortia, but only if the consortia have strong leadership. External organisations cannot substitute for this leadership. Page 20
Clinical leadership is fundamental…  ‘management’ cannot be split off, leaving the clinicians able to remain in a Faustian relationship.
Suggestion 4. Balance quality, patient experience and cost incentives 

  • If GP commissioning is perceived to be focused primarily on cost, it will likely generate a strong physician and patient backlash. The NHS should provide consortia with balanced incentives. That is, the consortia should receive financial benefits (or penalties, if performance is poor) based not just on their performance in controlling the overall costs to the NHS of care for their population of patients, but also for the quality of care and for patient experience. The NHS and the Government should take care that communications about the programme to the public and to physicians make clear that it is not just about reducing costs, but also about improving the quality of care and patient experience. Page 21
Accountable know-how in relation to the patient’s particular pathway is about much more than cost.  The process of healthcare must be (and must be expected to be) a collaboration around a social object (the patient’s experience) in the full sense of the word.
Suggestion 5. Incentives for GP consortia to generate cost savings for the NHS should neither be excessively strong, nor excessively weak. GP consortia should have the ability to use meaningful incentives for their member practices. 

  • Each GP consortium must be ‘at risk’ in some meaningful way for the cost of care provided to the consortium’s patients; and the individual GPs within the consortium must have something ‘at risk’ as well. However, the risk should be for costs that the consortium can reasonably be expected to control, and should not be so large that it is likely to lead to under-treatment or avoiding the sickest patients. To succeed, GP consortia must be able to distribute savings and quality bonuses received by the consortium differentially to members based on their performance. Page 23
Risk must be defined and managed from the perspective of what is possible for the consortium, and not simply from the perspective of the risks that the Government wants to distance itself from!
Suggestion 6. The consequences for poorly performing consortia should be made clear in advance and should be consistently enforced. 

  • There should be financial consequences, at least to some extent, for the GPs in a consortium that persistently fails. Page 25
The license to practice as a consortium should be subject to performance, regulated by Government against demand-side criteria.
Suggestion 7. To the extent possible, minimise the ‘insurance risk’ that consortia bear. 

  • GP consortia’s exposure to ‘insurance risk’ should be minimised by requiring that they have a minimum size (probably 100,000 patients or more); by adequate risk adjustment; by requiring consortia to purchase reinsurance (‘stop-loss’ insurance which is initiated when a claim reaches the threshold) to cover outlier cases with extremely high costs; and by excluding high-cost, low-frequency illnesses from the consortia’s commissioning responsibilities. Page 26
Part of implementing suggestion 5 must include defining what risks can be borne by the consortium itself vs needing to be reinsured.
Suggestion 8. Either ‘real’ or ‘virtual’ budgets can work, but details matter. 

  • Giving consortia real rather than virtual budgets – that is, actually giving consortia the funds budgeted – has advantages, but is a high-risk activity. Whether budgets are real or virtual, it is critical that both the NHS and GP consortia have timely and accurate information about expenditure, and that consortia are able to keep track of services that have been provided, but for which payment has not yet been made. Page 27
It is horizontally transparent systems of accountability that are they key.  These depend of good systems of record, but also effective means of using these in support of systems of collaboration.
Suggestion 9. Encourage hospitals and specialist physicians to cooperate with GP consortia and remove barriers to cooperation. 

  • For GP commissioning to succeed, the NHS must find ways to give hospitals and specialist physicians incentives to cooperate with GP consortia. In addition, it would be helpful if the NHS made it more feasible for specialists to leave hospital employment and work as members of commissioning consortia. Page 28
Collaboration around the patient’s pathways involves not just effective relationships, but also an agile infrastructure of care providers that can be aligned to new definitions of patient need.
Suggestion 10. Assume that, even if the NHS creates perfect incentives, it is likely to take many years for most consortia to become highly competent 

  • Even if the NHS creates perfect incentives, it is likely to take five to ten years for most consortia to become highly competent. The Government should plan accordingly. Experience in the US suggests that organised processes of care and a collaborative group culture are essential for physician groups to function effectively; by definition, these take time to develop. Page 30
This is a process that needs to be supported, and it is a journey, not just a structure!


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