Governance in Integrated Delivery Systems: Serving the Public's Interest

Abstract

Pointer, Alexander, and Zuckerman are to be congratulated for advancing a cohesive set of hypotheses related to the governance of integrated health care delivery systems (IHCDSs). Not only do these assumptions define the key structural elements of governance that should be considered by existing or emerging IHCDSs, they provide a sound basis for further empirical research. Structure, however, is only one dimension of governance; it's the mechanism through which more fundamental behavioral attributes and relational assumptions are implemented. The behavioral dimension of governance refers to the prospective goals and objectives of an IHCDS, while relational assumptions reflect the environmental context in which these outcomes are to be achieved. The differences between multi-institutional systems (MISs) and IHCDSs punctuate the importance of these additional characteristics. As noted by the authors, MISs have generally employed horizontal integration to achieve financial security through increased inpatient volume and marketshare. By definition, IHCDSs rely primarily on vertical integration to address the comprehensive health and medical needs of a defined population. Since both organizational forms have employed similar governance models despite differences in their core purpose and business strategy, it is not the structure of governance but organizational outcomes that differentiate them. Therefore, the remainder of our commentary will address the environmental assumptions and organizational goals that define the outcomes of IHCDSs and ultimately shape their governance. The role of the IHCDS is to improve the health status of a defined population through the provision and coordination of a vertically and horizontally integrated continuum of services. The authors' definition, seems to assume that the IHCDS is a closed with all the attributes, abilities, skills, and influence necessary to have a measurable effect on a population. In fact, no IHCDS, regardless of the extent of its horizontal or vertical integration, can possess all such traits. Without a broad understanding of the goal to be achieved, the IHCDS and its governing board may not maximize their potential. Without interacting with the public sector health and health-related agencies, concerns like abuse, rape, sexually transmitted diseases, homicide, suicide, motor-vehicle accidents, and improved living conditions will not be fully addressed. Each are societally based factors that in some way affect a population's health status and must also be attended to. Thus, IHCDSs have a mission that is fundamentally social, rather than organizational--a mission focused on the communities they serve. If a community's social condition is described by its economic, health, and educational properties, then IHCDSs and their governing boards should reflect those areas that cannot only influence but change a population's health status. A new paradigm must, therefore, be derived from which to view developing IHCDSs and their governing boards. There are, after all, not three but four factors that make up IHCDSs. The first three are well-addressed in the article: the roles of institutions, physicians, and insurance. Each of these factors leads to a complex confluence of roles, responsibilities, and influence in the alignment of incentives around a single, presupposed, clear, consensual, and overriding goal. It is assumed that all stakeholders understand the goal of an IHCDS and are willing to forgo independence to achieve it. However, human service organizations are composed of individuals who, regardless of the amount of an IHCDS's centralization, are motivated by concerns evolving from their perspective of the problem, their education and experience, and their biases. For example, the historic values and cultures of organizational members of an IHCDS often conflict, as evidenced by proposed consolidations of clinical services. Although presumably to the financial advantage of the system as a whole, the elimination of duplicated services through consolidation frequently limits economic growth and changes the institutional character for individual system members, both of which have been sources of pride for the community and the institution's governing board. …