Health Care Delivery: Lessons from Cleveland, Kaiser, and Canada

A Renal Week public policy symposium used current health care models to illustrate how care delivery systems can be used to provide more cohesive care to consumers.

Randall Cebul, MD, general internist and director of the Case Western Reserve University Center for Health Care Research and Policy, described the current health system in most of the nation as fragmented, with physicians having limited accountability and health care consumers frequently changing doctors and health care plans due to unemployment and lack of insurance portability. This fragmentation of care creates what Cebul terms “insurance churn,” a system where insurance companies have little incentive to invest in preventive care and chronic disease management due to the transitory nature of insurance coverage.

The Better Health of Greater Cleveland program was presented as an example of a collaborative care model that works to avoid fragmentation of care by creating a system where health care institutions are accountable through public reporting of clinical outcomes stratified by disease condition, type of insurance, and provider type. The Cleveland program started in 2007, and outcome data have been mixed thus far in terms of results, but this system of open reporting and accountability is expected to increase good health outcomes for patients with chronic diseases. Along with this collaborative care model, Cebul provided several other remedies to fragmentation, including increasing pay for performance incentives, using the patient-centered medical home model, and capitation of payments to providers.

The opposite of fragmentation of care, according to Alain Enthoven, PhD, a health economist with Kaiser Permanente, is the integrated care model, for which Kaiser is a prime example. The goal of an integrated delivery system is to create a streamlined, one-stop shop for health care consumers through patient-centered, integrated care, a continuity of care not found in typical American health care, according to Enthoven. Physicians benefit from a culture of teamwork characterized by an alignment of incentives through capitation, salaried pay, shared practice guidelines, and physician leadership through self-governed group practices. Enthoven decried current health reform efforts to include a public option, stating that integrated delivery systems like Kaiser may be pushed out of the insurance market. He recommended instead that insurance companies need the freedom to compete on their own merit by increasing quality and decreasing costs of care (6).

Adeera Levin, MD, described how “necessity drives innovation” in a fixed system and explained chronic kidney disease and end stage renal disease care through the lens of Canada’s single payer system. The Canadian government distributes funds to 10 provinces that create their own budgets and may add supplemental funding. Citizens with conditions deemed medically necessary can receive medical care and never see a bill. Although there is variability among provinces, the universal tenet of nephrology care is “equitable care across all stages of the kidney disease continuum, regardless of age or employment.”

The British Columbia Renal Agency, directed by Levin, who is herself a practicing nephrologist, created a “kidney care service delivery framework” that has become a model of care delivery for several other provinces. Health care is delivered within an integrated system combining clinical care based on best practice models, fiscal accountability, and a systemwide information management system. Allied health professionals provide multidisciplinary care for early stage chronic kidney disease (CKD) management, with nephrology care added on as patients get closer to end stage renal disease. Preliminary data from Levin’s cohort have been overwhelmingly positive: Patients seen longer in the early stages of CKD have increased survival once they start on dialysis, patients with an eGFR of <15 maintained kidney function for a median of 18 months before needing dialysis, and despite growth in their CKD population, dialysis incidence in British Columbia decreased from 5 percent to 3 percent, saving $3.2 million to be used elsewhere in the system.

While the collaborative care, integrated care, and single payer models all have their weaknesses, using successful elements and learning from their mistakes can help policymakers as they continue to craft changes to the current system of health care delivery.