If you?ve had this feeling of déjà vu lately when it comes to hearing about integrated delivery systems, it's because we?ve been through this before.
Now the buzzwords are ACOs and bundled payments; 15 years ago they were all about capitation and the inevitability of the California delegated model. Integrated delivery networks of the 1990s didn?t deliver on most fronts, not on being profitable in many instances, and especially not in truly integrating care. And they were pretty lousy at running managed care organizations.
So are we headed for the same disappointment this time?
That question is addressed in the November issue of Health Affairs by Lawton Burns and Mark Pauly, professors at the Wharton School of the University of Pennsylvania. They conclude that policy makers need to be realistic about the promises of accountable care organizations and suggest that ACOs are likely not a ?silver bullet? but rather ?bronze buckshot? -- part of a wider array of efforts to achieve lower-cost, more efficient healthcare.
In the déjà vu department, Burns and Pauly also wrote a piece for Health Affairs 10 years ago on why IDNs failed. Among the reasons: IDNs had no centralized control mechanisms, they diversified into new business lines they didn?t understand, and they put more emphasis on being contracting cartels than they did on integrating care.
In their article published this month, the two academics note that today's ACOs have tools that the old IDNs didn?t have, including health information technology, data analytics and decision support systems.
Neil Minkoff, a former medical director at Harvard Pilgrim Health Care and at the IDN Partners Community Healthcare, made a similar point in a recent interview with HealthLeaders-InterStudy: ?With EMRs now, there's a better shot at using systematic decision support, and trying to push people into integration and protocols. If you look at the organizations considered the gold standards?the Mayos, Kaisers, Geisingers?there isn?t a lot of room for freestyling. The docs there are expected to follow the protocols and guidelines. To succeed, groups buying up physician practices or merging will have to do a culture change and say to doctors, ?Autonomy isn?t on our agenda. We know everybody following their own path isn?t really working.??
The Affordable Care Act bet big on ACOs by making Medicare pilot programs a central piece of reform. Today's IDNs entering into ACO arrangements will likely do a better job of coordinating care than their 1990s counterparts, but they will have to do a substantially better job to improve care and make a dent in escalating healthcare costs.
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