The Forum

How this Israeli health system gave primary care a seat at the table, and how you can too

by Paul Trigonoplos

There's a global push for integrated health networks tasked with managing a population's health to budget. In every version—Integrated Care Systems in England, Ontario Health Teams in Canada, Accountable Care Organisations in the United States, etc.—governments are pushing hospitals to partner across the continuum to find success.

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In the dozens of conversations I've had with systems creating integrated networks, one question always comes up: What about primary care? In most westernised countries, GPs are incentivised and paid differently than hospitals, creating a tension that's tough to overcome when partnering.

We have clear guidance here—primary care is necessary to manage a population's health for two reasons: GPs can catch risk factors before they escalate and require acute care, and they can deliver care at lower-cost sites.

However, recognizing that GPs are a critical partner doesn't get down to brass tacks—and thus a second question arises: Well, then how do we bring them into our system's governance?

The true currency of governance: Decisions

There is no one-size-fits-all model here: Some systems give GPs little power, while others place them at the helm. This variance makes sense, because when successful systems choose where to place a new partner in their governance models, they focus less on hierarchy and instead base the structure on what critical decisions that partner is best-suited to make.

In other words, successful systems know they need to answer two questions before creating an organisational chart:

  1. What are the mission-critical decisions that we're going to have to make as a system?
  2. Of that inventory of decisions, who on our team (including our new partner) is best situated to make them?

How Clalit gives primary care a seat at the table

One Israeli system has done this extraordinarily well: Clalit is Israel's most successful health maintenance organisation—a vertically integrated, nonprofit entity responsible for both insuring and delivering care for its members. Clalit, which owns 14 hospitals and covers 3.8 million lives (about 60% market share), exists in a market where financial success happens when the collective can deliver quality outcomes below budget. So, it's in Clalit's best interest to ensure that their decisions are allocated to the part of the system best able to make them—especially as they get closer to the patient.

At first glance, Clalit's reporting structure looks like any other multigeographic, multi-divisional institution: a board at the top guiding strategy, a chief executive who marshals teams toward collective goals, and two co-equal branches of delivery—primary care and hospital care—that manage the cost and delivery of services for Clalit's insured population.

What makes Clalit stand out is how they allocate authority for issues that fall at the regional level—decisions that don't fit into a doctor's remit or into the purview of the board or C-suite. Clalit has found their district managers are best suited to make decisions on these 'middle' issues, such as adjusting system strategy to the local context, deciding on referral patterns, adjusting their regional portfolio of services, and meeting cost and quality targets set by the board.

This middle-system power allocation has two key benefits:

  1. Regional managers can both interpret top-down strategy as well as pull information from frontline staff more effectively than other leaders in the system.
  2. With regional managers assuming responsibility for middle-system decisions, executive and frontline leaders are able to devote their time to the decisions they are best situated to make.
 

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