Exploring value: Dr. Steven Laitner

Exploring value: Dr. Steven Laitner

As an independent healthcare consultant and general practitioner, Dr. Laitner discusses value-based organizations with Anna van Poucke.

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Dr. Laitner has helped a number of UK healthcare organizations become more value-based, by introducing the concept of the ‘Accountable Lead Provider’ which has proven to be an effective way of applying many of the principles discussed throughout this report.

Anna: For a majority of patients in many countries, care starts with the general practitioner, but once an individual is referred to an in- or out-patient facility, the process can become complicated, especially in the case of co-morbidities; a lack of coordination between providers, with patients shuttled between different specialists and caregivers.

Steve: I agree. Neither GPs nor hospitals are currently capable of providing the complete pathway of care, and GPs who hold commissioning powers in the UK do not really have the skills or time to micromanage all the elements of complex healthcare systems and pathways. I think to do so, is neither right nor possible. One alternative is to follow the lead of other industries and contract with a lead provider to manage the entire continuum for a particular program of care such as musculoskeletal conditions, diabetes, and the frail elderly. This idea is at the heart of the Accountable Lead Provider model (see below).

Anna: This is like having a hub at the center of the system – but these contractors do more than just oversee care.

Steve: Absolutely. That is why I call them ‘Accountable Lead Providers,’ who provide a substantial amount of community-based specialist services as an alternative to hospital outpatients, and, where necessary, will subcontract the in-patient part of a patient’s pathway care. They also hold responsibility for the total budget for a program of care, such as respiratory health, or a care group, such as the frail elderly. They are fully accountable for both the quality and the cost of the entire patient pathway across primary, community and acute care. They are ideally placed to work with all stakeholders to define the standard pathway and manage the gateways through the tiers of care. The key activities they provide include support for case management, care navigation, shared decision-making, personal health planning, support of self-care and also importantly caregiver support.

Anna: In this report we mention the importance of outcomes, and the need to link these to care planning and measurement. How can an accountable lead provider ensure a strong focus on outcomes?

Steve: Care planning must be linked with outcome development and measurement. Therefore, the methodical use of care plans is part of the contract between the commissioning group and the lead provider. The contracts should be fully or partially outcome-based with a capitated payment, of which a proportion would be based upon outcomes. There is usually a sweet spot of contract elements related to outcomes, which in my experience lies around 5-10 percent of the contract value. However, rather than focusing on a specific percentage, make sure the amount is large enough to drive change but small enough to make sure providers do not fixate on just the outcomes that are stipulated.

Anna: There are a number of good outcome measurements. For musculoskeletal conditions, the Oxford Hip and Knee Score has proved reliable. For patients with respiratory diseases, a reduction in the number of people smoking or a fall in hospital admissions are also positive outcomes.

Steve: And patients have to play a part in defining and reporting outcomes, to ensure that they reflect what is really important to them as human beings. In addition to existing PROMs, you can think of so-called ‘patient defined outcomes’ on an individual basis. These measures will vary according to an individual’s personal goals, whether it’s the desire to hold a pen and write a letter, or walk to the shop for groceries, or take a week’s holiday with the family, or simply enjoy a pain-free night’s sleep.

Anna: What is the role of the GP in this model?

Steve: The GP will remain the first point of call and will initiate a referral to the hub when they feel a patient would benefit from multidisciplinary specialist services. The aim is to avoid unnecessary referrals or treatment, and provide care in the most appropriate setting. What the most appropriate setting is will depend on the individual’s needs and preferences at that time.

Anna: For this model to work, we will need a new type of coordinating professional that understands the different parts of the care network and can work with health professionals and patients. Potential candidates could be a GP, nurse, community geriatricians or general hospital physician. One of their most important tasks, besides delivering care to patients, is to manage individual care pathways and support GPs and specialist providers with patient referrals.

Steve: This is a key role and careful thought needs to go into their remit and skills and who may fulfill that role. The role of the key worker, case manager, care navigator, care planning support worker are all essential and may not all have to be health or care professionals, peer support can play a key role. The accountable lead provider may wish to create some form of joint venture between provider partners such as social care, third sector organizations and independent providers, or alternatively it may simply manage subcontractors. In the case of frail elderly services, it is likely to be dually commissioned by health and social care.

Anna: In addition to joint ventures, the provider may enter into special purpose vehicles, alliances, partnerships or loose federations, but the key constant is that there is a single, accountable governing body, whose activities are fully transparent, in order to maintain a steady focus on outcomes.

Steve: That focus is critical. And, because the contractor is both providing and sub-contracting, it has a strong incentive to manage complex and long-term conditions more effectively, and strive for earlier and cheaper interventions, including self-care and even prevention. The structure of the contract gives providers a real incentive to improve patients’ lives, including solutions that may lay outside the health system, in what I like to term a ‘biopsychosocial’ model of care.

Accountable Lead Provider model

The accountable lead provider, under the outcome based contract with the contracting party (clinical commissioning group, insurer etc.), delivers the bulk of specialist ambulatory and community services for that specific program of care. It works with patients and all care providers involved to manage the boundaries between tiers of care and shift care to the most appropriate setting, incentivizing a ‘shift left’ through the tiers of care.

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