Health Care Delivery Integration Research Articles

The Economic Case for Vertical Integration in Health Care

Summary There is an economic case to be made for the vertical integration of health care delivery and financing as the model best suited for owning the whole patient, as we introduce the term. This entails complete responsibility for a patient, spanning coverage, care delivery, and administrative processes. Owning the whole patient requires aligning financial incentives between providers, payers, and patients; establishing holistic access by providers and payers to patient health data, coupled with analytics tools to guide care management and coordination; and developing seamless and personalized consumer experiences around administration of care and coverage. Vertically integrated models of care and coverage that achieve these requirements have the potential to lower health care costs, improve care quality and outcomes, and enhance the patient experience.

Supports and hindrances to the integration of co-located services in multiple models of primary health care delivery Integration in co-located primary health care services

Introduction: In 2008 the Australian Government funded the establishment of GP Super Clinics based loosely on the UK Darzi polyclinic model. The intention was to collocate general practice and allied health services. The initiative was centred in primary care and integration between primary care and specialist medical or hospital services was not a prime objective. No specific model for how integration was to be achieved was mandated. This study is an evaluation integration of six GP Super Clinics in South Australia and Victoria funded by the Australian Primary Care Research Institute conducted between 2014-5. Methods: The design was a multiple case study (mixed methods design). Quantitative data was collected using three surveys (clinic manager survey, health professional survey, patient survey) and qualitative data from patient and health professional focus groups. Each collection tool was applied concurrently at each case study site. Survey tools were administered first, sample GP management plans collected, and then focus groups conducted. Explanatory sequential process was used as the basis for data analysis (quantitative data then qualitative data to explain findings). A case study database was established to collate information collected for each site. Each case study site was described in terms of the seven components (for example, level of variety of services co-located, level of internal service integration mechanisms). Quantitative survey data was manually coded, entered into a Microsoft Excel spreadsheet and imported into SPSS for analysis. Frequencies, means, standard deviation and range, as well as cross-tabulations with percentages were calculated. Results: There was mixed evidence that the health clinics were aligning their services to match surrounding community demand with only two centres basing their decisions on service development on local research. All clinics started with a core set of services that expanded over time usually starting with at least GPs. In Australia, all GP pathology, radiology, specialist services and some allied health services have a Medicare funded rebate. While often there was no out-of-pocket expense to clinic patients access for some services or for patients not considered disadvantaged required a ‘gap’ payment. This impact on access to comprehensive care for some patients The clinics had similar ways of reimbursing health care professionals but there was some variation for allied health professionals. Nurses were most commonly salaried across all organizations and the State funded clinics were able to provide allied health free to patients by having the resources to pay staff a salary. Patients and practitioners felt the collocation improved patient convenience and satisfaction. Practitioners identified a lack of formal integrated care structures. The important role of nurses working in these clinics at integrating care between other health professionals was identified. Patients participating in the focus groups sensed that integration was not occurring in the clinics. Conclusions: When contemplating integration health professionals focused on communication, trust, familiarity and the importance of process in defining if it could be successful. Integration tended to be understood in terms of sharing of information about an approach to treatment, treatment proposed for the patient and not about how treatment was delivered. Patients perceived an absence of communication and information sharing among health professionals. Lessons learned: Health professionals are the drivers of integrated care. There were low rates of integrated care across all health service models in our study. Currently there are few incentives to achieve integrated care in Australia Limitations: Limited resource study examining only 6 of the 64 funded clinics in a limited geographical area. Data coded by only one researcher. Suggestions for future research: To what extent have resources and infrastructural supports been concertedly reviewed for their facilitation or obstruction to integration within different co-located PHC models within GP Super Clinics?

Evaluation of health care delivery integration: the case of the Russian Federation

Objectives: -evaluate the level of fragmentation/integration in the Russian Federation health care -explore tools to strengthen integration with the focus on economic incentives Methods: survey of physicians (1700 in 3 regions of Russia), review of the literature Results: 1) the conceptual framework is suggested for the evaluation of health services delivery integration, as well as around 50 indicators for teamwork, coordination and continuity of care. 2) Physicians report low level of teamwork, coordination and continuity of care in Russia. 3) Bundled methods of payment (prospective payment for both outpatient and inpatient care, including repeated admissions) is the most immediately viable approach to encourage integration of providers. In Russia there is a good evidence of the method known as 'policlinic as fundholder' (fundholding method). It creates incentives for policlinics to plan all stages of service delivery, cooperate and communicate with hospitals, refer patients to the best providers, expand activities to avoid aggravations of chronic cases.

Community‐directed interventions strategy enhances efficient and effective integration of health care delivery and development activities in rural disadvantaged communities of Uganda

The community-directed interventions (CDI) strategy achieved a desired coverage of the ultimate treatment goal (UTG) of at least 90% with ivermectin distribution for onchocerciasis control, and filled the gap between the health care services and the communities. However, it was not clear how its primary actors--the community-directed health workers (CDHW) and community-directed health supervisors (CDHS)--would perform if they were given more responsibilities for other health and development activities within their communities. A total of 429 of 636 (67.5%) of the CDHWs who were involved in other health and development activities performed better than those who were involved only in ivermectin distribution, with a drop-out rate of 2.3%. A total of 467 of 864 (54.1%) of CDHSs who were involved in other health and development activities also maintained the desired level of performance. They facilitated updating of household registers (P<0.05), trained and supervised CDHWs, and educated community members about onchocerciasis control (P<0.001). Their drop-out rate was 2.6%. The study showed that the majority of those who dropped out had not been selected by their community members. Therefore, CDI strategy promoted integration of health and development activities with a high potential for sustainability.

Commentary on: “The future of health care in Canada”

Steven Lewis and colleagues have produced a thoughtful article in the British Medical Journal w1x on the challenges facing the Canadian health care system. Lewis et al. point out that the Canadian health care system, an icon of Canadian values, is going through a period of turbulence and a crisis of confidence. They rightly point out that Canadians continue to favour a publicly funded, comprehensive health care system, but seem pessimistic about whether it is sustainable; and that increasing privatisation, in numerous forms, has crept into the system. Though numerous reports from federal and provincial governments have called for substantial reforms, the authors feel that achieving a consensus among players in the health care field remains elusive. To date, after withdrawing money from the health care system in the 1990s, the federal and provincial governments now have simply started to put more resources back into the system without carrying out the fundamental necessary reforms. Lewis and colleagues indicate that privatisation, seen by some as a solution, is really a red herring. They are right to be concerned about privatisation judging by recently published reports by a federal government senate committee w2,3x and an advisory commission to the Premier of the province of Alberta w4x. Lewis et al. suggest the need for primary care reform, implementation of population and health strategies, development and use of performance measures and other important reforms. They then suggest that the political solution may be in convincing the provinces to give over jurisdiction on health care to the federal government to carry out crucial reforms and policies. Lewis and colleagues may have in fact raised a red herring of their own suggesting that the federal government would somehow be more capable than the provinces in carrying out the important needed reforms to the Canadian health care system. In fact, it is interesting to note that in their article, Lewis et al. have not mentioned the fact that both Quebec w5x and Saskatchewan w6x have created independent ‘‘Royal-type’’ Commissions which, in the past year, have produced major recommendations for reform of their health care systems respecting the major principles and values of the Canadian health care system. In fact, the report of the Commission in Quebec (known as the Clair Commission) created a surprisingly major consensus among all the actors in the Quebec health care system. Consensus, therefore, is possible. The problem is not which level of government will carry out the necessary reforms but the capacity of governments to develop and implement medium and long-term strategy and planning, as well as the necessary investment in order to carry out these reforms. This is particularly true for carrying out primary care reform, an essential element in promoting greater integration of health care delivery at the local and regional levels. There is nothing to suggest that the federal government would be less driven by the immediate political electoral agenda and the day-to-day crisis management than the provincial governments.

Healthcare delivery integration and the evolution of internet infrastructures and complementary assets

Although at present no country has embraced completely the internet to redesign healthcare delivery, there has been for several years a keen interest in the incorporation of the latest information technologies in the integration and general transformation of healthcare delivery. This will create a new industry, called e-healthcare, which will make use of the technology infrastructure which supports an increasingly powerful internet adopted by the economy at large. Some countries will lag behind others, depending on the evolution of an array of infrastructures covering not only purely technological factors, but managerial, organisational and institutional ones as well. The evolution of technology, or its transfer to less developed countries, can be better understood by the outward translation in rich versus richness space of a trade-off curve which illustrates the amount and complexity of information interchanged via the internet. By examining a simple integration model consisting at one end of patients with access to computers, intermediary clinics and finally hospitals and research centres at the other end, and the interaction of these three stages with six evolutionary complementary assets and infrastructures, a level of integration for any region or country may be estimated.

Integration of health care delivery in the Eastern Mediterranean Region of the World Health Organization

This paper reviews developments in the integration of health care delivery in the Eastern Mediterranean Region. It describes the integrated intersectoral support of socioeconomic community development (district health systems and basic development needs), the functional intrasectoral integration of health services and interventions, and health resources integration.

Dental Management Service Organizations: Lessons From Medicine

While management service organizations are new to dentistry, they have existed in medicine for many years. The author examined why they developed and what happened to three of them during 1998 to provide dentistry with insights into the future of dental management service organizations, or DMSOs. The author identified and examined the three largest physician practice management firms, or PPMs, as of early 1998. He monitored their stock prices and fiscal changes through 1998. He also tracked all publicly traded DMSOs for growth and evaluated their stock price changes. Economic pressures to control the cost of health care led to the development of organizational structures designed to increase the cost effectiveness of, and to control more variables associated with, health care delivery. The lure of vertical integration of health care delivery with the resultant control of multiple variables-including primary and specialty care, pharmaceuticals and hospitals-promoted the development of many PPMs and DMSOs, although many variables differ for dentistry. The realities associated with the loss of control in the corporate model, the lack of sufficient operating margins to support investor expectations and plummeting stock prices call into question the wisdom of universally embracing similar models for dentistry.

Deconstructing the Columbia/HCA investigation.

Every issue raised by the current investigation into the business practices of Columbia/HCA serves as a signpost for the progress and problems inherent in market-driven health care reform. Actions against Columbia/HCA by regulators reveal deeply rooted resistance to the profit-motivated reforms embodied in the company's philosophy: the public's reluctance to accept necessary reductions in excess hospital capacity; the legal and cultural obstacles to the overdue alignment of physician and hospital economic interests; and the myriad reimbursement and accounting problems involved in the vertical integration of health care delivery. The investigation also underscores the antiquation of the reimbursement mechanisms and control systems in place for financing the delivery of care to Medicare beneficiaries.