Mark S. Soberman, MD, MBA, FACS: I think that one of the problems we’ve had in healthcare is that most health systems have felt they need to be everything to everyone. It’s some of the rural hospitals that have closed, for example. I do think we need to rethink how we regionalize and rationalize care, and that’s going to be a journey because everybody has their own idea of what that should look like. But in real value-based care, you should be doing the things that you do really well, with terrific outcomes, in high volume, and at low cost. We need to think, “Are there services if we regionalize then centralize?” Where we had rural hospitals, maybe we need freestanding EDs [emergency departments] and outpatient and ambulatory facilities, but we don’t need an inpatient facility. But we then need to have a hub-and-spoke system that can get those patients who need care.

Bruce Feinberg, DO: But you’ve got to be able to do thrombolysis.

Mark S. Soberman, MD, MBA, FACS: Exactly.

Bruce Feinberg, DO: Because now we have a therapy that we didn’t have 2 decades ago, but now we have therapeutics that are actually life and death defining.

Mark S. Soberman, MD, MBA, FACS: Right. The other piece is that we need to get—for example, in thrombolysis—that information and that expertise out to the people at the point of care, as well, so that they can provide that care.

Dana Macher: Yes, I agree. I think it gets back to being able to offer this breadth of services. When you’re talking about rural closures and things like that, a good example is how Intermountain created a virtual hospital. I think it’s going to be innovations like that that help get over this hump so that we don’t have gaps in care.

Bruce Feinberg, DO: I think Intermountain is a great example that you brought up. If we look at what we’d like to see as the IDN [integrated delivery network] movement continues to expand, there are probably certain areas like that where you could look at best-in-class. Here are a few of them. I’m curious whether anybody’s aware of offering a best-in-class and cross-continuum coordination of care. Are you aware of an IDN, or have you had an experience where you would argue that somebody’s got that down? One that has come up before in my work has been Geisinger.

Mark S. Soberman, MD, MBA, FACS: Yes.

Bruce Feinberg, DO: You often wonder when you have these examples, Are they 1-off situations? Are they so unique in some fashion? Can Geisinger, because of its geography, do something like that, but it wouldn’t be possible let’s say in most places? Or is it just a great model and needs to be replicated?

Mark S. Soberman, MD, MBA, FACS: They are an integrated system that has a payer, and they do cover the entire continuum. All their doctors are employed. They’re at the Cleveland Clinic, Mayo Clinic. They just happen to be in a smaller metropolitan area. I think this also speaks to their leadership. David Fineberg is a very innovative guy. He’s getting them to deal with things like social determinants of health and food deserts and all those kinds of things. I think they’re just very forward-thinking. I’d like to think it’s replicable because it’s a great model, but I don’t know.

Dana Macher: I agree with that. I do think it’s replicable. A lot of it has to do with how they have really good systems, and a lot of times, that is the biggest barrier to being able to deliver.

Bruce Feinberg, DO: That was going to be my second question of best-in-class. Where are there really great IT [information technology] systems and interoperability across the care continuum that are often critical to having the care continuum be successful? I don’t know whether there are other examples of that, but that would be one. Population health management seems to be one that would come up on the list of what you’d want to see accomplished. I’m listening because we have these rare examples, but we don’t seem to have persistent models.

If we think back, though, maybe the one system that was being touted to have been the model was Kaiser. There has been a lot written about the “Kaiser-ification” of the United States healthcare system, which didn’t materialize. It does make you wonder whether such high praise is duly earned. It’s not coming up as we’re having this conversation about best-in-class, and yet it has been unique. I’m curious about your thoughts about the Kaiser system.

Mark S. Soberman, MD, MBA, FACS: I think you have to think of which Kaiser you’re talking about. If you’re talking about Kaiser in California, there’s a lot that’s good about that and worthy of emulating. If you’re talking about Kaiser in the Eastern United States, unfortunately they haven’t been able to replicate their model very well because they don’t have the same degree of integration.

Michael Kolodziej, MD: They don’t because they don’t have enough membership to have those comprehensive resources. They have to outsource stuff, and that leads to a deterioration of the ability to execute the management. It’s interesting because we talk about oncology, and I must say, I’ve never heard anybody say that Kaiser had a particularly good oncology delivery program. Please correct me if I’m wrong, but I haven’t heard it.

Dana Macher: No.

Mark S. Soberman, MD, MBA, FACS: I haven’t heard anything good or bad.

Bruce Feinberg, DO: No, but you hear about population management and preventive health. You hear about those things. You don’t often hear about specialty service.

Michael Kolodziej, MD: That’s exactly right. That’s what I was thinking. So in primary care, excellent. For specialty care, help me out here.

Mark S. Soberman, MD, MBA, FACS: I’ve got nothing.

Bruce Feinberg, DO: I’m the moderator.

Michael Kolodziej, MD: No, I’m serious. I think the question is whether these kinds of models, as they have evolved now to this risk model, look more and more like regular health insurance. It’s really good to have people who don’t have a lot of medical illnesses because coordinating their care is not that complicated. They don’t cost any money, and we can give them everything they need. It is interesting. I must say—and I’m an oncologist, so I hate hospitals—it’s very hard for me to see hospitals really get to where you want them to go in this discussion. I just don’t see it. I have a hard time believing it.

Bruce Feinberg, DO: I struggle, and this is why I wanted to bring it up, because there are these examples like Geisinger. In everything you read about it, it seems to be doing all the things that we envision to be the next better place, the next better platform of healthcare. It’s not just what you read from the pundits but also what you hear from the communities that it’s serving. And then there’s the question of how it’s replicable but it’s not replicated.

Dana Macher: Right. I think a lot of that, again, has to do with systems. A lot of these hospitals and these businesses are really struggling just to get up-to-date with Medicare mandates. It’s really difficult. And so I think that until that happens, you’re not going to see this be replicated.