Debate on integrated care pilot projects

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 1/2003

Abstract

There is debate concerning the experiences with integrated care projects that are taking place in different autonomous regions. The experiences are not homogeneous, they do not have the same characteristics and there is debate on how integration should be done, and even if it should be done at all due to a lack of evidence available. See J. Pou et al, 2005, for a summary of experiences.

Purpose of health policy or idea

Integration of primary and hospital/specialised care, in the hope that this will improve efficiency, reduce costs and improve the quality of health services to patients. The autonomous regions are trying different ways of integrating care and of achieving better coordination among primary and specialized care.

Main points

Main objectives

The objectives are to:

• integrate care (at least primary and hospital care);
• increase efficiency through better coordination (e.g. reduction of diagnostic tests and procedures) and economies of scale that reduce management costs;
• reduce the costs of services e.g. to chronic patients;
• improve quality through an integrated care approach (e.g. reduction in medical errors, better attention (more coordinated) to patients with multiple diseases);
• increase patient satisfaction through improving the NHS image: less bureaucracy and higher coordination among services;
• transfer risk to providers through per capita financing;
• pay providers for care rather than for processes.

Type of incentives

1. Prospective financing: per capita financing
2. Some are trying to implement some sort of incentives linked to the achievement of pre-defined objectives

Groups affected

Doctors and other professionals in the NHS, patients, health managers and providers

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

The ever pursued objectives of efficiency and quality, together with budget constraints, have forced health authorities to try different formulas of organizing provision, purchase and financing of public health services.

Integration and/or better coordination of primary and specialized care is now a method tried by different regional health authorities, as well as transferring risks to providers by means of paying providers on a per capita basis. The evidence in other countries as well as the theoretical advantages of integrated care has impelled the on-going pilot projects. See for example the case of Catalonia in HPM report (1) 2003.

Also demographic and lifestyle factors (like higher prevalence of chronic diseases) have contributed to the implementation of integrated care experiences.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

There is no white paper on integrated care that clearly defines the objectives, the process and the characteristics of integrating care. Experiences from other countries (mainly USA) have contributed to the implementation of integrated care pilot projects in different regions and those experiences have contributed to expanding them to broader areas within each region (e.g. Catalonia), even though still not much evidence is available on the achievement of the desired goals. The idea of implementing integrated care has come from health authorities and in some cases from other influential agents (e.g. the "Consorci Hospitalari de Catalunya", an association of publicly-owned health care providers).

Integrated care can also be seen as one step closer to the reforms being implemented within the on-going process of decentralization; the following steps are, e.g. in the case of Catalonia, allowing some public providers to have greater management flexibility and autonomy (e.g. transforming them to public enterprises, as it is the case with the "Institut Català de la Salut"), and further decentralization towards local governments.

Initiators of idea/main actors

• Government: Regional governments

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Local level - Catalan Health System, Navarra Health System, etc.

Stakeholder positions

Public administration in general is very supportive; it is the leading actor.

Health professionals and managers of primary care are somehow unenthusiastic about the reform because they fear that it will give hospitals and hospital managers even greater power within the public health system, so that the role of primary care will be reduced. They also argue that there is not much mobility of professionals across primary and specialized care. Furthermore, they claim that if hospitals will gain even more power this may reduce the quality of the NHS through a less population-oriented care, a reduction of patient satisfaction, a reduction in the budget assigned to research in primary care, public health and prevention.

Health professionals in general are "waiting and seeing".

Patients and society in general are not usually asked about their opinions on the reform.  

Actors and positions

Government
Regional governments	very supportive		strongly opposed
Doctors and other health professionals	very supportive		strongly opposed

Influences in policy making and legislation

There is no specific legislation on this.

Actors and influence

Government
Regional governments	very strong		none
Doctors and other health professionals	very strong		none

Positions and Influences at a glance

Adoption and implementation

The hospital and primary care sector and hence the professionals working in those health areas are involved in the implementation process of pilot projects. Financial and other incentives are needed for their success: payment on a per capita basis (well adjusted to population needs that take into account e.g. needs on prevention and old age patients needs), incentives to change the actual structures and change the way of thinking of both primary care and hospital doctors, towards a culture of cooperation rather than competition.

Other needed measures are:

• an integrated information system and better coordination channels between primary and specialized care. It appears to be important that the information system is integrated (see e.g. Vázquez et al., 2005), but it also has to be flexible so as to take into account specific needs (e.g. clinical information) of the different types of care implied (e.g. primary and specialized).
• shared protocols or clinical guides (which appear to be needed for a good service to patients), integrate patients' views and the society in general (e.g. neighbours associations); 
• mobility of health professionals among service levels (e.g. hospital and primary care) and better management of human resources;
• creation of methods of action and protocols shared among the different levels of health services, which may allow a reduction in the number of diagnostic and therapeutic tests and improvements in the continuity of the care process to patients;
• giving the responsible centers the power to contract/buy services;
• participation of affected groups in the establishment of the integrated institution's objectives, budgets and monitoring and evaluation of results

Monitoring and evaluation

Little evidence is available on the results obtained by the existing experiences, even though it seems that the transfer of risks to health providers created by the payment on a per capita basis has not created risk selection problems.

However, most experiences are quite new, so that not much evidence is available yet.  Moreover, the experiences are not homogeneous, it seems that regional health authorities that want to improve the system try to copy (with ad-hoc constraints and differences) the formulas tried by other regional health authorities. A nation-wide comparison of results is needed, but there are not yet any signs of that being done.

Results of evaluation

Event though little evaluation has been done, we know that:

• The degree of integration is not homogeneous among autonomous communities and in some cases even within individual autonomous communities
• In most cases, social services are not integrated
• Only some cases include an integrated information system which is also shared among levels of services
• In most cases the central management of the integrated services is the responsibility of a hospital. However, there also exists a separate board of managers for primary care.
• Also, in most cases there is a separate budget for primary care, which may be higher or lower, compared to that of specialized care, depending on each case.
• Only in a few cases there exist shared protocols or clinical guides (which appear to be needed for a good service to patients).
• In general, there is no evidence of the results achieved through integrated care, but some consider that the per capita payment system to providers, which accompanies some experiences of the integrated care process, and which means that risks are transferred to providers, is not producing adverse selection problems.
• There is a need to evaluate the different experiences that are taking place so as to be able to choose the better ones and implement them.

Expected outcome

Effects will partially depend on the way integration can be/is done and the participation of the affected groups, especially doctors and other health professionals, who are the ones that have to provide services to patients and who can make things work better or worse. 

It is also important that hospital care does not become even more important than it is now, and that the role of primary care in the system is not reduced; for that, the election of managers of integrated services is an important issue.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

The integrated care pilot projects are expected to increase efficiency and quality, but there is still the need to continue reforming the process and learning from existing experiences.

References

Sources of Information

Jonay Ojeda, José Manuel Freire and Juan Gervás (2006): La coordinación entre atención primaria y especializada: ¿reforma del sistema sanitario o reforma del ejercicio profesional?, Revista de Administración Sanitaria, 4 (2): 357-83.

Pou, Joan, Joan Gené, Cristina Cámara, Ikaki Berraondo, Joan Puig (2006): Gerencia única: una ilusión sin evidencia. Atencíon Primaria, 37 (4), pp. 231-234. 

Consorci Hospitalari de Catalunya: Recomenacions i precaucions sobre l'ús de l'assignació per càpita a Catalunya (2001).

Various articles in Revista de Administración Sanitaria, (2006).

Vázquez, Mª Luisa, Ingrid Vargas, Joan Farré and Rebeca Terraza (2005): Organizaciones sanitarias integradas: una guía para el análisis", Revista Española de Salud Pública, 79 (6), nov./des. 

Author/s and/or contributors to this survey

Esther Martinez-Garcia

Suggested citation for this online article

Esther Martinez-Garcia. "Debate on integrated care pilot projects". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/es/b8/1