Evaluating Catalan Integrated Health Care Schemes

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

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Abstract

Development of integrated health care organisations in Catalonia, particularly of population-based purchasing systems, is arousing notable interest both among academics and within health authorities. This report gives an account of an exhaustive evaluation of these organisations, published in 2007, and the main conclusions of analysis thereon, in order to describe significant elements of the Catalan model, and to identify success factors and obstacles in these new organizations.

Purpose of health policy or idea

The purpose of this initiative, summarized and commented in this report, is to provide an in-depth analysis of the coordination and integrated health care model developed in Catalonia. This evaluation is the point of departure that serves to draw conclusions, highlight weak points and catalogue future challenges to the implementation of new initiatives in this area.

Main points

Main objectives

• Describe a coordination model in the integrated health care
• Analyse the various experiences of existing integrated organisations in Catalonia, and evaluate their economic and health outcomes
• Evaluate the impact of these organisations on the Catalan health care system
• Analyse and spread good practices of integrated hlealthcare organisations
• Identify future areas of development to improve efficiency in the integrated health care organisations in Spain
• Consider opportunities for the development of new initiatives

Type of incentives

• Definition of a guide for the study of integrated organisations
• Case study with multiple evidence sources

Groups affected

Providers, managers, Public purchaser, Professionals, patients

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

The unplanned nature of the origin of health system integration has created a diverse model in which organisations share characteristics, but notable differences persist. In particular, organisations differ in their form of inter-organisational relation (integration degree: virtual or real) and in the degree of development of some organisational elements that influence assistance coordination and efficiency.

In spite of these differences and the absence of a homogeneous model, the consolidation of Catalan purchasing schemes may be considered an opportunity to develop innovations in the health system with potentially significant impact, both on efficiency and on user-perceived quality. These innovations have been a major change due to institutional needs to respond via disease management to problems that will continue to grow in the coming years (in particular, attention to chronic diseases, comorbidity and dependency).

Political and economic background

In recent years, providers, purchasers and health policy analysts around the world have expressed an increasing interest in the development of integrated delivery systems (IDS). There is notable consensus that IDS represent an innovative form of organisation capable of providing an answer to the emergent challenges in modern health care (chronic diseases that need coordinated attention; out-patient care and day surgery replacing hospital care, else).

IDS have appeared, most especially, in countries with many private providers and fragmented health care delivery systems, such as the United States, and in countries with social insurance systems (Germany, Austria) which have linked insurers and provider organisations with managed care.

18 integrated health care schemes in Catalonia

In Catalonia, integrated care organisations have been progressively developed inside a mainly state-run health care system (National Health System with diversification in ownership). The LOSC's (Llei d'ordenació sanitària de Catalunya, Health Care Organisation in Catalonia Act) approval made it possible to transfer management of new primary care centres to external providers of the ICS (Institut Català de la Salut, Catalonia Institute of Health) - amove that in turn facilitated horizontal and vertical integration that resulted in integrated healthcare organisations. Currently, eighteen integrated healthcare organisations exist in the Catalan healthcare delivery system.

Complies with

Need to analyze integrated health care organisations in depth, to recognize weaknesses and strengths that should support the decisions on the generalization of these organizations.

Purpose and process analysis

Current Process Stages

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

Origins of health policy idea

Integrated health care organisations in Catalonia were first established in the early 1990s, based on the integration of primary care centres not managed by the ICS at the time.

The original development of these entities was due more to a diversification policy in the provision of primary care within the LOSC, and, to a lesser extent, to a clear public policy of health system integration.

Leadership and economic incentives

Factors that stimulated the integration of organisations inside this legal framework were basically economic (cost containment and economy of scale), supported by certain hospital executives and by local administrations (in management consortia).

Consorci Hospitalari de Catalunya (CHC), the association of regional hospitals, entrusted to the Servicio de Estudios y Prospectivas de Salud (SEPPS), a specific research unit created by CHC in order to provide technical assessment to their own members, a thorough study of the model of integrated healthcare organisations in Catalonia, which had just been published and which provided a broad overview of these organisations.

Initiators of idea/main actors

• Government: Nowadays, the integration between primary and hospital care has become one of the priorities of the Catalan government health policy. It has declared that structural changes will be carried out to foment the integration of these two service levels.

• Providers

• Patients, Consumers

• Others: The association of regional hospitals has promoted the constitution of Integrated Health Care Organisations by publishing their experiences and advices.

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Local level - There has been a trend of expansion in assistance services to dependents (elderly nursing home residences, home assistance) and those in public health (health protection activities).
Pilot project - Pilot projects have been developed for the purchase of services across a population split into five geographical areas, which promotes supplier integration and improves the incentives to treat the problems in a more cost-effective manner.

Stakeholder positions

Most notably, the expansion of these organisations "happened" without support from the policy side: There was no political leadership that would have stimulated implementation, though it there were no political constraints either.

The main stakeholders involved in the development of IDS were the hospital managers, given their economic interest, and the local governments, which were keen to retain welfare services in their territory. Consorci Hospitalari de Catalunya also promoted the constitution of integrated healthcare organisations by publishing their experiences developed in this area.

More recently, the main health authorities of the Catalan government announced that the development of these organisations was one of their highest priorities.

Actors and positions

Government
Catalan Ministry of Health	very supportive		strongly opposed
CatSalut (Catalan Health Service)	very supportive		strongly opposed
local authorities	very supportive		strongly opposed
Providers
Primary Care Centers	very supportive		strongly opposed
Hospitals	very supportive		strongly opposed
ICS (Catalan Institute of Health)	very supportive		strongly opposed
Patients, Consumers
Patients	very supportive		strongly opposed
Associations
Consorci Hospitalari de Catalunya	very supportive		strongly opposed

Influences in policy making and legislation

The introduction of integrated health care systems did not require the passing of a specific law. However, structural changes might soon require modifications, if the announcements of the health authorities were to be put in place.

Legislative outcome

pending

Actors and influence

Government
Catalan Ministry of Health	very strong		none
CatSalut (Catalan Health Service)	very strong		none
local authorities	very strong		none
Providers
Primary Care Centers	very strong		none
Hospitals	very strong		none
ICS (Catalan Institute of Health)	very strong		none
Patients, Consumers
Patients	very strong		none
Associations
Consorci Hospitalari de Catalunya	very strong		none

Positions and Influences at a glance

Adoption and implementation

Despite the fact that there were very few common denominators that would have jointly determined the process of integration (vertical integration from a hospital level to upstream levels of service provision), the Catalan IDS organisations creatively implemented the process in ways that resulted in different delivery models.

The most prominent differences concern the extent of integration (number of units that provide the service), the reference population, and the judicial forms under which they have been constituted (either management consortia with single-ownership or organisations with different ownerships that establish links between primary care and hospitable attention).

The problems during implementation were partly due to the non-existence of health authority planning, and partly to the maintenance of a purchasing system for line of services. These problems reduced the incentives for coordination with other suppliers and between assistance levels, which assure gains in efficiency and equity in access.

Monitoring and evaluation

Mechanisms of evaluation have not been developed by the health authorities in charge of the provision of health services. Monitoring and internal evaluation by these organisations and pilot initiatives turned out to be insufficient from the performance approach. The information produced this far focused on intermediate outputs of different units and has not been related to health outcomes.

In reference to the capitation-based payment experience (2001-2005) that included three integrated healthcare organisations, wider mechanisms have been developed to evaluate results, but up to now have provided only preliminary and partial results, that have contributed to some recommendations for generalisation.

The external evaluation published by Consorci Hospitalari Catalunya about the integrated healthcare organisations has been the most exhaustive evaluation of this area. It consists of case-by-case analyses of the application of a guide for the study of these organisations, with each analysis covering internal organisational elements, the environment determinants, the process development of coordination, and the performance level of these IDS organisations compared to the commitment / agreement to their final objectives. This evaluation provides a detailed analysis of the strengths and weaknesses of a sample of these organisations, and in addition, has generated a general vision of the Catalan healthcare integration model.

Review mechanisms

Mid-term review or evaluation, Final evaluation (external)

Dimensions of evaluation

Structure, Outcome, Process

Expected outcome

The expected effects of integrated delivery system organizations consist, in general, of an increase in global efficiency of the system by means of, firstly, horizontal and vertical integration of healthcare levels and, secondly, units that facilitate coordination between levels. The first creates economies of scale, as well as a decrease in transaction costs and unnecessary services. Vertical integration also supposes an improvement in coordination and control along with continuous assistance, and provided that the incentives are suitable, should ultimately also favour better cost-effectiveness.

However, to achieve these aims, a major effort is expected to redesign incentives geared toward the desired development of integrated care organisations, such as the introduction of a real capitation-based payment system, development of management tools and performance evaluation by government bodies. 

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 expected effects from the implementation of integrated health care organizations are minor compared to what should be expected. Some aspects necessary for the proper development of these organisations have not been applied during the process of implementation. In addition, some deficits exist in the planning (population of reference) and in the development of mechanisms for coordination between units and with external suppliers. The tools of performance evaluation are very limited, since they place greater emphasis on the incentives for efficiency inside a given level of care, and less on coordination and cooperation between care levels.

The capitation payment pilot project constitutes an exception that has addressed some of these questions, and has consistently promoted incentives for effective care coordination. There remains, however, a need to modify some elements of the design of the purchasing model, such as: the alignment with a needs-based (and risk-adjusted) capitation funding system (not for effective cost) and the elimination of purchasing contracts for care assistance.

The exhaustive analysis of these organisations and of the integrated healthcare model developed in Catalonia reveals a definite need to intensify the development of elements that stimulate cooperation and integration, without which the desired results will not be obtained. Improvement and subsequent generalisation of the capitation funding system is the solution to the mentioned shortfalls.

References

Sources of Information

• Vázquez Navarrete, ML and Vargas Lorenzo, I. Organizaciones Sanitarias Integradas. Un estudio de casos. Barcelona.Consorci Hospitalari de Catalunya, 2007.
• Ibern Regás, P. Integración asistencial: fundamentos, experiencias y vías de avance. Barcelona. Elsevier-Masson, 2006.
• Consorci Hospitalari de Catalunya: www.chc.es
• Various specialized newspaper articles. Available at: www.elmedicointeractivo.com
• Various specialized newspaper articles. Available at: www.diariomedico.com

Reform formerly reported in

Catalonia: Integrated HC Pilot Project Process Stages: Implementation

Integrating health and social care Process Stages: Implementation

Debate on integrated care pilot projects Process Stages: Pilot

Author/s and/or contributors to this survey

Gabriel Ferragut Ensenyat, reviewed by Sophia Schlette

Suggested citation for this online article

Gabriel Ferragut Ensenyat, reviewed by Sophia Schlette. "Evaluating Catalan Integrated Health Care Schemes". Health Policy Monitor, February 2008. Available at http://www.hpm.org/survey/es/b10/1