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6 Tightly Structured Health Care Delivery Organizations Organized health care is not an abstract concept, a fantasy, or an unattainable ideal. In fact, millions of Americans already benefit from health care organizations that use information systems and teams of clinicians to provide safe, reliable, and efficient care. Many of the patients who use these organizations are unaware of the advantages that their systems offer—until those patients leave, and rediscover what health care is like when physicians do not share the same medical records, when letters and lab tests get lost on a regular basis, and when there are no processes that address their needs in between doctor visits. Once you have had well-organized health care, the acceptance of anything less is difficult. Some of the best-organized health care providers in the United States have familiar names, but many do not. Even when the names are wellknown , they are not necessarily the most prestigious in U.S. medicine. The Veterans Health Administration (VHA, or as it is also known, VA), for example, was ridiculed in movies in the post-Vietnam era because the care it provided was considered so poor; today, the VHA leads the country on many measures of quality of care. In contrast, many Americans have never heard of Geisinger Health System, the northeast Pennsylvania delivery organization with an innovative approach to coronary artery bypass graft (CABG) surgery that was featured in a front-page story in the New York Times in May 2007. In this chapter, we will describe four tightly structured delivery organizations that are defining organized care and its benefits for the country. We call these organizations “tight” because they own their hospitals and other facilities, and their physicians are salaried employees . In three of the four examples, these organizations include their own health insurance plans, so that they have complete control of how health care is financed and delivered. Three of these organizations 98 Chapter 6 survived major crises in the last ten to twenty years, which doubtlessly influenced the ability of their leadership to implement changes that were often considered radical. We will not give comprehensive descriptions of these organizations, each of which are worthy of book-length treatments on their own. There are many interesting initiatives under way within these organizations that we will not discuss in this chapter or book. We should also note that these organizations are not the only ones in the United States or elsewhere from which there is much to be learned. The Group Health Cooperative in Seattle, Intermountain Health care in Utah, the Mayo Clinic in Rochester, Minnesota, the Cleveland Clinic in Ohio, and several others could have been used as examples. For the purposes of this book, however, we will focus on one or two key aspects of organized care that these four organizations demonstrate particularly well. We will begin with the VHA, which has shown how a truly dysfunctional organization can be transformed into a model of reliability for the country—in just a few years, and without a huge infusion of new resources. We will turn to the Virginia Mason Medical Center in Seattle, which has adapted lean management techniques from Toyota to redesign care for patients with back pain and other conditions. Then we will describe Geisinger Health System’s innovative CABG program, which offers a glimpse of a new model for paying for health care. And we will conclude with a look at Kaiser Permanente’s creative systems to keep populations of patients as healthy as possible. The VHA: The Turnaround If the VHA turnaround story has a single lesson for the rest of U.S. health care, it is that even a huge underfunded government bureaucracy can become highly reliable in key areas and much more efficient, if the organization has strong leadership and a mandate to change. The VHA provides care to 5.3 million U.S. military veterans—a population that is older, sicker, and poorer than the general U.S. population. The budget available to the VHA does not increase nearly as much from year to year as medical spending in the rest of the U.S. health care system. Somehow, though, the VHA is managing to set a standard for the country in safety and reliability. Some readers who have not followed the VHA story may be wondering , “Wait! Are we talking about the same VHA I know about?” Their impressions of the VHA were shaped by...

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