I’m a bit of a Cold War nerd. I loved the novels of John le Carre, and can still recite the list of leaders of the Soviet Union from the pictures that hung on the walls of my 10th grade social studies classroom. In some ways, the world seemed simple. There were two big alliances: NATO and the Warsaw Pact. The world could be divided into East and West. While these blocs came to represent competing ideologies and politico-economic systems, the original purpose was to assure mutual defense through shared, coordinated military effort. Over time, it came to seem that not only could the world be divided into two camps, but that it had to be. You were either East or West. Yet we forget that the majority of nations in the world, especially in Africa but even in Europe, the epicenter of the Cold War, were part of the non-aligned movement.
Health care in 21st century Wisconsin is coming to resemble mid-20th century Europe. Two large state-wide alliances of health systems are emerging – Integrated Health Network (IHN) and abouthealth. The former includes, among others, Froedtert, MCW, Wheaton, Ministry, Dean, and HSHS, while the latter counts Aurora, ProHealth, UW Health, ThedaCare, and Gundersen Lutheran among its members. Such accountable care organizations (ACOs) are an approach to managing health for populations. Alliances of providers (including physicians, hospitals, and others) jointly take responsibility for both the costs and outcomes of care. The specifics can vary widely, but some of the common principles include:
- The providers take on some or all of the financial risk for providing care. Rather than payment for volume, there is payment for value. Better quality and lower cost are rewarded; poor quality or high cost put the provider at risk.
- Value is driven by coordination of care, emphasis on prevention, and use of shared data to drive informed decisions by both clinicians and administrators
While this sounds appealing in theory, it is difficult in practice. Studies of ACOs to date show that achieving the desired combination of improved outcomes and lower cost is challenging at best, with many performing below expectations. Scale seems to matter, as does expertise. And most of the experience to date is with adult populations (especially Medicare).
As we work to figure this out in Wisconsin, Children’s is poised to be one of those non-aligned nations, working with both alliances to advance the health of children in our state. With our scale and expertise, not only in specialty and primary care, but also with care management and coordination (as in Children’s Community Health Plan, our Medicaid HMO), we are uniquely capable of taking on the task of managing the health of the population of the children in the state. We like to say kids are not just small adults. This is as true when it comes to managing their health as when managing their illnesses.
Which is why you didn’t see our name listed in either of the two statewide alliances listed above. We do, and hope to continue to, work with both. There are only about 1.5 million kids in Wisconsin, spread out among many different health systems. If we are forced to pick one side or another, it is likely that neither of them will have sufficient scale and expertise to do the best job of managing the population of children, in sickness and in health. I hope the health care equivalent of the Berlin Wall doesn’t get in the way of our vision of the kids in Wisconsin being the healthiest in the nation.