Across the pond–lessons from the US on integrated healthcare

Abstract

Despite its single-payer structure, the NHS has often struggled to deliver integrated care to patients. The announcement of the integrated care pilots in High Quality Care for All (Darzi 2008) provides an opportunity for the NHS to experiment with new, radical approaches to the integration of care. The proposal was partly influenced by the experience of integrated health care systems around the world: this report seeks to explore some of the specific lessons from the United States. The development of integrated care in America has been a response to the potentially perverse incentives in the operation of the health insurance market and the fragmentation in the delivery system. The conceptual framework for integration is different from the model in the English NHS and so, for example, there is little to be learned from the American experience about the integration of health and social care services. However, important lessons from the American experience can be identified and these can be grouped under three cross-cutting themes: Lesson 1 There are many different models of integrated governance in the US but the successful approaches are always built upon strong clinical leadership and robust management processes. In addition, specific potential lessons include: • A diversity of approaches to governance among integrated care organisations (ICOs) could enable the development of locally sensitive and practical governance structures. • Governance structures are only truly effective at enabling integrated care if they are combined with a culture that prompts the delivery of integrated care. This is clearly shown in the experience of integrated payer systems. • When there is a network of partner organisations working together, there needs to be clarity about who is accountable for ensuring the delivery of integrated care. In the US one approach is to create a new entity tasked with bringing together the network, while an alternative is to clearly designate one of the existing partners as responsible. • Corporate governance systems in integrated organisations operate in a wider regulatory environment which is designed for fragmented delivery systems. Thus governance systems in integrated organisations need to be able to meet both the internal (integrated) and the external (non-integrated) requirements. Lesson 2 American integrated health care systems have sophisticated approaches to risk management and the use of incentives. The integrated payer systems seek to align incentives within a single organisation to minimise risk, whereas the integrated networks have developed strategies to share and transfer risk between health plans and providers. Four potential lessons for ICOs are identified: • • There are increasingly sophisticated risk adjustment methodologies being developed to set capitated payments for providers. To incentivise the delivery of integrated care, the balance between ‘risk minimisation’ (usually associated with vertical integration) and ‘risk transfer/sharing’ (as in virtual integration) needs to be reflected in the payment systems. • There is a need to manage income from different sources and payment systems, so that the delivery of integrated care is properly funded and incentivised. • There is a need to develop robust internal management systems to minimise provider risk. Hospital–physician integrated systems have developed service line management that could be used across care settings. Lesson 3 Integrated health information technology is essential in enabling the integration of care, integration of services and integration of structures. Four specific lessons from the US are: • There are alternatives to large comprehensive IT systems that work well in network models of integration. The prime IT focus must be on systems to improve the coordination of care. Integrated delivery systems are in the ‘consumer health information business’, resulting in a focus on member/patient access through an interactive web portal. • The IT systems can also support the information flows required for effective performance management.