As patients with multiple conditions becomes more common, patients risk becoming lost in different parts of the care system, with each provider concerned only with its own narrow parameters of success. True value is determined by the total outcome as a result of all the care received, which may require considerable coordination, to ensure that providers are aware of and complementing each other, and assuming collective accountability for outcomes. Without such joined-up thinking, value can ‘leak’ out of the system. For example, if a patient has a hip replacement operation and the initial physiotherapy sessions are delayed, the hip can lock, leaving the patient far less mobile and comfortable.
Value is typically achieved over a longer period, measured by indicators of the quality-of-life outcome, including life expectancy. Patients with multiple chronic conditions should, where possible, be cared for at home – or close to home – embracing self-care and encouraging more independent lives.
Where this is not feasible, they are best served in integrated units responsible for their total care. These teams consist of clinical and non-clinical personnel that treat the diseases and all related conditions, working together toward a common goal to maximize outcomes.
For chronic conditions, these goals are, more often than not, related to the patient’s quality-of-life rather than their medical state. For certain complex conditions, it may be prudent to bring in, or cooperate with, super-regional providers possessing high degrees of specialization. Frequent formal and informal meetings enable participants to exchange and review vital information and build an atmosphere of trust.
This is harder than it sounds, given the fragmented state of many healthcare systems. Even in single, public health systems such as the UK’s NHS, administrators struggle to pull together different parts of the care continuum. Lack of interoperability is one of the biggest barriers; without technical standards, organizations struggle to share and make sense of data in a standard format.
Concerns over information security and privacy have further slowed progress, while different payment schemes must somehow be sufficiently aligned to ensure common goals. And of course, clinicians may not always be accountable to the same leaders, and could be more loyal to their own group and organization than to a patient that crosses different provider boundaries.
No single system is best suited to achieve value for all patients in all settings. The appropriate approach will depend upon the patient, his or her social group, the disease segment and, to some extent, the geography. Coordinated care is more common where there are perceived problems with continuity of care, as well as with groups such as long-term care patients and the elderly. Those requiring elective or acute cardiovascular care will benefit from a more specialized approach, calling for single care pathways.
Patients with single conditions may be better served in integrated ‘focus clinics’ that specialize in one health condition and pool their expertise toward fast, efficient care. The Sun Yat-sen Cancer Center in Taiwan (see Defining and measuring outcomes ) is focused solely on cancer and brings together a diverse range of specialized clinicians in medicine, surgery, pathology, radiology, nuclear medicine, radiation, oncology, medical physics, psychiatry, anesthesiology, gynecology and rehabilitation medicine.
All processes and innovations are geared toward developing the highest standards of cancer care, with patients able to move seamlessly between different specialists in the same building.
A third option is embedded care, used by regional hospitals with limited services, who work with the most appropriate (and often supra-regional) provider to augment their own care, using shared, integrated pathways. The most complex care, such as diagnostics and/or interventions, is often outsourced to the specialized, supra-regional provider.
Regional health systems, especially those on the periphery of a county, may struggle to provide coordinated, often complex, care for their patients. Although patients can be referred to other systems for the entire treatment process, they would have to travel to each consultation, and the local hospital would lose vital income, which could threaten its entire existence.
In the Netherlands, one regional hospital chose an ‘embedded’ strategy for prostate cancer care, working together with a specialist provider as the preferred, subcontracted supplier. In this form of alliance, clinical pathways are integrated, and diagnostics and aftercare take place in the local center. The intervention is carried out in the specialized center and the outcome of the total pathway is measured. Such an arrangement enables patients to receive most of their care close to home.
Disease programs offer a manageable entrée into coordinated care, dividing patients into segments and developing pathways for these groups that cross different providers, with agreed outcome scores. At a more mature level of integration, the system forms managed clinical networks with formalized governance treatment, research and education, and joint development of care pathways. Patients are under the wing of care coordinators, who take overall responsibility for their welfare throughout the pathway.
The most advanced practice involves formal clinical networks or integrated care organizations, with official contracts between contractors and subcontractors, or even totally integrated organizations.
In the US, accountable care organizations (ACOs) have emerged, featuring a group of health providers working together for a defined population of patients. Reimbursements are closely tied to measure the quality of care, using a variety of payment models including capitation and fee-for-service. The ACO is ultimately accountable to patients and payers.
Rather than formally ‘integrate,’ systems could instead agree upon contractual relationships with contractors and subcontractors, with bundled payments based upon their expected costs. Such a route gives the commissioning party greater choice of contractor, thus preserving competition.
Cancer, elective care, maternity care and acute cardiovascular care are all potential candidates for bundling. Even the much-maligned fee-for-service approach can be fully value-based for preventive interventions with a proven record of delivering value.
In this intensive and highly coordinated approach to community mental health, an interdisciplinary team consists of a psychiatrist, one or more nurses, social workers, substance abuse specialists, vocational rehabilitation specialists, occupational therapists and certified peer specialists. This team is jointly responsible for all its patients, whether they are outpatients or in psychiatric hospitals. The whole team works under the supervision of a qualified mental health professional.
One concern over integrated care systems is that provider consolidation will lead to quasi-monopolies that push up prices. This is more likely in less densely populated areas that can only accommodate a limited number of providers. Indeed, a number of ACOs in the US have failed, partly because provider consolidation has created near-monopolies in some regions. To promote competition, any associated health plan should restrict price increases and link payment to outcome targets.
Experience with integrated systems has been mixed, as not all participating providers necessarily offer the highest quality care. In addition, some specialists, accustomed to a certain level of revenue under previous structures, may not react well to a drop in income due to an increased emphasis upon primary care.