Thoughts on Integrated Care

• A Context for Integrated Care
• The Emergence of Purchasing and the Opportunity for “Seamless” Care
• Recent Experience of “Managed Care”

• The Incentive for Integrated Care
• “Integrated Care” and the CRHA
• Forces for Integrated Care
• So, a Possible “How” of Integrated Care?
• Conclusion
• References

Background

A Context for Integrated Care

It has long been a stated goal of most publicly funded health care systems that the various levels and/or stages of care should be better “integrated”. Although this has been interpreted in many different ways, and not always benignly, the general desire has been that client/patient transfers between the usual levels of care (ie: primary – secondary/tertiary – continuing care) should be as easy as possible from that client/patient’s viewpoint. The words, “seamless continuity of care” have often been used to describe the desired goal and, in almost every case, this “seamlessness” is intended to mean from the point of view of the client/ patient. And the viewpoint of the informal carer (relative or friend) must not be forgotten. So, “seamlessness”, if it is to be a goal, should probably be seen from the position of both client and direct informal carer, both of whom can be considered “consumers”.

Much of the criticism of existing arrangements, from which the desire for integration of care has sprung, emanates from the apparent difficulty that health care provider organisations have in managing the interfaces with other providers, particularly, but not only, at the nexus of hospital admission or discharge. Some of the problem must also be attributable to the “referral” process usually employed by the medical profession. At worst, this referral process can appear much like the child’s party game of “pass the parcel”. At best, the hand-over from one health professional to another can actually be the integrating force.

Possibly because of confusion surrounding the term “integration” and, perhaps sometimes for less innocent reasons, public health care organisations and even whole systems have pursued management integration. The word “integration” has many meanings and nuances. Many think in terms of the economic concepts of “vertical integration” and “horizontal integration”, both of which relate to organisational integrations, usually for either efficiency or market advantage. Such organisational behaviour, although in vogue at various times since the Industrial Revolution, was particularly prevalent through the 1960s.

A number of health systems sought, over perhaps the last 25 years, to achieve integration of care by vertical organisational integration. The general experience of that was that it was unsuccessful. Certainly there were examples where this approach actually worked. However, they did not represent the norm and are probably entirely attributable to the managers and other professionals involved, who would, through their own determination and skill, have achieved a significant degree of continuity of care whichever route they had taken.

During the 1970s and 1980s, in vertically integrated models, such as Area and District Health Authorities in the UK, Area Health Services in Australia and, perhaps to a lesser degree, Area Health Boards in New Zealand, the results were often that the hospitals consumed so much of the available resources that community and continuing care services became “poor relations”. Among these services, relatively starved of resources, were aged and disability care, ambulatory care and mental health (including intellectual disability). From this history emerged the term “Cinderella Services”  ¹   which was more of an indictment of the systems and the approaches than the people who tried to make them work. A manager facing the compelling urgency of her/his hospital’s apparent need for resources and the “political” power of certain hospital staff and professional interests, should perhaps not be judged too harshly if she or he provided those resources at the expense of other, less pressing service needs.

Perhaps the great irony, however, is that it has since become quite obvious that if primary and community health services are optimised they can result, in many disease areas, in fewer and less acute admissions and consequently opportunities for resource savings in secondary and tertiary care.   ²   Equally, optimal resourcing of community care and continuing care facilitates appropriate earlier discharges, again resulting in opportunities to save resources in hospitals.

The Emergence of Purchasing and the Opportunity for “Seamless” Care

Over the last quarter of a century, methods of funding public health care have been sought that would result in fairer and more appropriate distributions of resources, both geographically and between the different modalities of health care. Population-based funding of regional, area and district health care provider configurations were pursued in various jurisdictions.   ³   This at least attempted to address geographical inequity. Not entirely successfully, however. Perhaps the greatest flaw in the logic of population-based funding, during this time, was the idea that provider organisations should be funded for population needs. That assumed that there were sufficient incentives for those providers to really address those needs.

In the early 1990s, the concept of “purchasing” health care emerged.  ^{4  ,   3}  

The general idea was that organisations charged with the “health of the population” (purchasing authorities, commissioning authorities, funders, etc) should receive a population-based allocation of funds and spend those funds by “purchasing” health care services from all (publicly- and privately-owned) provider organisations. For the first time, organisations were formed with the remit to actually represent the interests and wishes of communities and consumers, without having the burden of the conflict of interest associated with the ownership of provider organisations. Therefore the organisational demands and the pressure from staff groups, etc, were the problem of provider managers rather than purchasers. That left purchasers reasonably free to seek out and promote appropriate care, best practice care and optimum value for money.

Importantly, there were now organisations which could, if they wished, really pursue “continuity of care”, without the encumbrances of organisational pressures and behaviours. Such “seamlessness” could be progressively encouraged through the process of contracting with the various provider organisations offering primary, community, secondary, tertiary and continuing modalities of care.

There have been some varied results, with some important, if limited, successes.

Recent Experience of “Managed Care”

In the US most funders of personal health care insurance are employers who pay the premiums as part of employees’ wages, salaries, conditions, etc. By the 1980s, many US employers’ costs associated with employees’ health insurance had risen to unacceptable levels, causing, in some cases, a critical loss in international competitiveness. As a response, the private health care insurance market produced organisations called Health Management Organisations (HMOs).

A number of HMOs operated in a vertically integrated manner, owning some provider organisations, while others simply contracted with a range of providers. By delivering more comprehensive primary care and by having business arrangements with secondary and tertiary care providers, they were able to reduce premiums substantially. The cost of doing so, however, was to reduce insured people’s choices about which provider HMO (and in some cases which physician or other health care professional) they could access. Given the fundamental importance of “choice” in the US system, although HMOs blossomed, indemnity insurers also survived. During the 1980s, a number of HMOs as well as indemnity insurers were the subject of business failure. The costs of secondary and tertiary care and the cost of “choice” were still crippling many employers.

By the turn of this decade another player was emerging in the US health care market. What were soon to be known as “Managed Care Organisations” came into being. These organisations offered their services to HMOs and indemnity insurers alike as well as, directly, to employers. Their approach was to go further than HMOs in managing health – to actually managing care. Freedom of choice of provider was further restricted, through either contracting or ownership. More fundamentally, MCOs sought to take positive action in keeping members well and in ensuring that interventions, when called for, were minimised. The two most publicised, and arguably most notorious, outcomes were:

Forces for Integrated Care

The CRHA definitions for integrated care focus on two of the three principal dimensions or purposes of “integrated care”. They certainly address the implied “gate-keeping” function, with its collateral value for money implications. Additionally, they address the pursuit of “appropriateness of care and interventions”, also perhaps implicit in the gate-keeping role. The CRHA does not, however, appear to address the pursuit of “seamless continuity of care”, which many argue is not only implicit in, but is fundamental to, the concept of “integrated care”.

Clearly, a purchaser can pursue “integrated care” either by purchasing a service combining components and/or levels of care, or by contracting for different modalities of care with different providers in such a way as to ensure the necessary linkages and continuity. In both cases the purchaser needs to put in place appropriate incentives to ensure that providers behave in the desired way. The fundamental question is, perhaps, “What is the best integrating force?” CRHA proceeded to suggest that:

        â€¦there are three options listed here for removing barriers to integration: