Twenty years ago this month, California created an organizational architecture for integrated delivery systems taking global capitation—the restricted Knox-Keene (RKK) license.
At its creation, I envisioned the RKK as a pathway to virtual Kaisers.
This post distills the RKK’s guideposts for provider organizations on that pathway.
It also summarizes a straightforward path to transcend the biggest barrier to fluid, integrated care—healthcare’s Tower of Babel.
Organizational architecture for full risk. Many provider organizations do a very good job delivering patient care; very few have the systems or experience to effectively administer benefit arrangements.
Taking full risk for patient care requires both.
RKK provider organizations meet all Knox-Keene standards governing the provision of healthcare services, including requirements to provide continuity of care, assure timely access to healthcare services and separate medical decisions from fiscal management.
Without a strong financial footing, provider systems taking full risk put their patients at risk for care disruptions. RKK licensees must maintain a minimum net worth and assure that incurred-but-not-reported claims are reflected in the organization’s books and records.
Licensees also need grievance systems to address patient and non-contracting provider complaints.
For full risk arrangements to succeed, a solid delivery system needs to be matched with a strong administrative infrastructure to manage the benefit arrangements.
RKK license holders provide care under contracts with full service Knox-Keene plans (e.g., Anthem, Blue Shield, United). These full service plans handle enrollment, marketing and overall plan administration functions.
While some RKK licensees have a developing interest in contracting directly with large employers and other payers, that hasn’t happened yet.
Most of the measurable improvement in the delivery system will be made at the provider level.
Instead of health plans contracting with integrated delivery systems to provide care, integrated delivery systems with direct payer contracts (e.g., Next Generation ACOs) will subcontract with health plans or others to provide the necessary administrative infrastructure.
This could be another valuable role for non-profit health plans.
With the right providers, in the right markets, putting providers at the front-end of the payer relationship will advance patient, provider and payer interests.
Transcending the Tower of Babel. One of healthcare’s most painful painpoints is the existence of valuable patient data locked in multiple EMRs/other data systems that don’t communicate.
Healthcare’s Tower of Babel is the biggest barrier to the development of successful, virtually integrated, patient-centric delivery systems.
Legacy EMRs are built on different platforms, use different system architectures and deploy different data structures and standards. None were not built with cross-system communication in mind; few have this capability.
In addition, many EMR vendors are reluctant to communicate with competing systems for proprietary and competitive reasons.
While data interoperability will be a reality some day, that day won’t be tomorrow.
As a first step, let’s tackle the biggest problem—data access across EMRs and healthcare organizations.
Health eWay (HeW) securely pulls the complete meaningful use Stage 2 CCD data set from multiple EMRs and presents the combined data on a user’s mobile device or computer.
Importantly, EMR vendors aren’t required to do anything more than meet their existing obligation to provide a CCD upon a request from an authorized user.
Because HeW is data standard agnostic, data exchange protocol agnostic and data location agnostic, it presents an open-ended pathway to innovation.
As an example, there is tremendous opportunity to improve patient care and reduce healthcare costs by increasing the information flow between ambulances and EDs.
To build virtual Kaisers and drive systemic improvement, it’s critically important that we transcend healthcare’s Tower of Babel.
Gary Mendoza is CEO of Health eWay. The first restricted Knox-Keene license was issued on his last day as California’s health plan regulator.