17 Sep Healthcare Integration & Value
HEALTHCARE INTEGRATION & VALUE
Authors: John Kueven (USA, Co-chair), Hwee Sin Chong (Australia), Shrikant Peters (South Africa), Urszula Szybowicz (Poland). Reviewed by Florian Trummer (YEL Alumni, Austria)
The concept of healthcare integration has been described in health systems literature over the past two decades, with the definition having developed over time in tandem with changes in healthcare services delivery globally. Such definitions are thus highly dependent on the context in which healthcare is delivered, and on which stakeholder perspective is being sought, including, providers, policymakers, funders, evaluators and most importantly, patients1.
Integration is a natural progression, first from treating individual patients not simply as a conglomeration of diseased organs, but holistically and comprehensively, to similarly understanding healthcare systems as ‘complex adaptive systems’, made up of multiple, intricately linked component parts, working in concert with each other to improve health as well as health equity as efficiently as possible.
The World Health Organization thus provided the following overall working definition of integrated service delivery; “the management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system”2.
The drive towards this ideal stems from a recent past in which there has been a significant rise in funding for single-disease developing world programmes, such as HIV or Malaria, with decreasing total resources for health services overall and a relative neglect of their underlying inter-connected systems such as human resources, supply chain management, information management and financing, which if more effectively managed, have potential to enable improved healthcare efficiency and effectiveness3.
How the definition of integration is operationalised, and which of its aspects is emphasized in different countries, is highly dependent on their differing contexts, especially as to how healthcare has been financed and incentivised, who’s opinion has been sought, which actors have agency and a set of certain minimum set of patient expectations from the healthcare sector, in different socio-economic contexts.
This can also be applied to the concept of value, which in its narrowest sense refers to a maximisation of efficiency, by generating the highest quality of care possible for funds spent on healthcare services, but in its broadest sense can also refer to the underlying values of the society in which the health system operates. Nevertheless, integration of healthcare services is seen as a means to the end of generating and reinforcing value/s. Engagement is required from healthcare workers, managers, and policymakers to reorient healthcare systems to provide an integrated service to better deliver this value to patients.
In this article we seek to more granularly dissect these two concepts at a national level, to demonstrate how different countries are defining and implementing integration, and what can be extrapolated from this, to better understand the meaning and sum of value in each country, and the concept as a whole.
All Australian and New Zealand citizens and permanent residents in Australia have access to Medicare – Australian’s universal health care scheme[i]. Medicare covers all costs of public hospital services. It also covers some or all the costs of other health services, including those provided by general practitioners and medical specialists, as well as covering part cost of prescription medicines. In 2018–19, this total health expenditure amounted to $195.7 billion, equating to $7,772 per person[ii].The Australian state, territory and local governments share responsibility for running the health system. The Commonwealth government administers Medicare; supports and monitors the quality, effectiveness and efficiency of primary health care services; and subsidises aged care services, such as residential care and home care, and regulating the aged care sector. State and territory governments manage and administer public hospitals, ambulance, and emergency services. The delivery of primary health and aged care services are generally through private providers who claim costs of care provided back to the Commonwealth through the Medicare system or other funding models.
Table 1. Australian Institute of Health and Welfare 2018. Australia’s health 2018: in brief. Cat. no. AUS 222. Canberra: AIHW.
In Australia, we would consider that value-based healthcare “is where we both measure the costs and resources we use for our healthcare services and also measure the amount of health benefit we get back from our healthcare services. It could be we give years of life to patients by reducing mortality or we improve the quality of years of life of patients by removing morbidity.’[iii] We aim to improve patient outcomes with lower healthcare costs, focussing on reducing low-value care. An example is the “Choosing Wisely” movement “that aims to effect a culture shift about how we think about medical tests, treatments and procedures”[iv]. This seeks to engage clinicians, consumers, associations and specialist colleges to promote a national dialogue on unnecessary tests, treatments and procedures, and support people to choose health care that is supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary.
Value-based healthcare is a simple proposition of considering both the outcomes that matter to patients, and the costs of delivering them. However, outcomes can mean different things to clinicians and consumers, and in Australia we have National Safety and Quality Health Service Standards[v] (which hospitals both public and private are accredited against), requiring us to partner with consumers in planning, design, delivery, measurement and evaluation of systems and services; and patients as partners in their own care, to the extent that they choose.
On the subject of “integrated patient‑centred care’. The objective is fourfold – to improve health outcomes while at the same time delivering a higher quality service to patients, lowering costs, and ensuring the wellbeing of the health workforce[vi]. The key point is that a genuinely integrated public system allocates resources to the parts that generate the best health outcomes[vii]. Because primary care and secondary care is funded by different levels of government and provided by different organisations and/or private businesses, integrated healthcare aims to overcome barriers between these services to improve access, continuity and quality of care[viii]. Given the challenges of an aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution.
In Poland, we are still dealing with many financial losses, which are caused by mismanagement and wasted resources. The COVID-19 pandemic has exposed organizational problems in healthcare around the world. Poland has also been affected in this way. In a report titled “Where is the money going missing in health care?” Konrad Hennig presents the weaknesses and shortcomings of the Polish healthcare system. Between 2009 and 2019, public expenditure on healthcare increased more than one and a half times with no noticeable impact of such a significant increase in the total funding stream on improving the performance of the Polish healthcare system.
Poland was parameterised by the European Health Consumer Index (EHCI) in these years in 6 categories. In 2009 Poland scored 565 points and ranked 26th, while in 2018 585 points and took 33rd place, which indicates that the quality of Polish healthcare has not changed substantially, despite a significant increase in expenditure, and the drop in ranking is due to the inclusion of more countries in the survey and quality improvements in other countries (e.g. Slovakia and Portugal). From the analysis of the scores achieved by countries in the EHCI, the key conclusion is that: there is no evident correlation between the amount of healthcare spending and the quality of national healthcare systems. A crucial role is played by the level of governance and the level of organization both at the level of the structure of the healthcare system separated into medical care and social care sectors, in the rules of financing providers and the practices of their operation. Which shows how important it is to strive to implement value-based healthcare and integration of care.
At present, the healthcare system focuses on satisfying the needs of staff and placing the interests of the sovereign in the background – keeping citizens as healthy as possible. Such action is the opposite of acting according to the principles of value-oriented and integrated medicine. However, to complete the picture of the issue of values and integration in the Polish healthcare system, positive aspects should be mentioned. In Poland, since 2017, the KOS-infarction programme has been in place to monitor the effectiveness of resources spent on post-infarction patients during hospital treatment, cardiac rehabilitation and cardiac specialized care. The results of the programme are very positive. The data shows that 12-month mortality after myocardial infarction is 31 percent lower in the group of patients who were included in the KOS-infarction programme. Among these patients the 12-month probability of major cardiovascular events is 25 percent lower than in the group of patients outside the programme.
Another positive development that can be observed in Poland is the eHealth (healthy data) portal, where the first quality indicators of treatment available to patients are appearing. This is most visible in ophthalmology – patients can see, for example, what the quality indicators for cataract surgery should be (the rate of negative change in visual acuity after surgery, the rate of endophthalmitis and the rate of posterior capsular rupture). These indicators are at the level of provinces, but, for example, indicators for the use of toric lenses are available for each hospital separately. There is probably no such detailed report available in any country in Europe and this is a major step towards the VBHC approach.
Hope for an improvement in the situation regarding VBHC and coordinated care is also given by the announcement of changes recently announced by the Polish Minister of Health, Adam Niedzielski at a press conference at the Lower Silesian Oncology Center in Wrocław. This is the direction of the act on quality in healthcare and patient safety. “This law will change the philosophy of the system,” said the head of the health ministry. To sum up, the situation in Poland regarding both integration and value-based healthcare still leaves much to be desired. Nevertheless, changes are being made which give hope for future improvement.
The current South African healthcare system originates in the democratic consensus established after the first free and fair elections held in the country in 1994. After a long history of racial segregation and inequitable access to care based on ethnicity, the National Health Act (2003) created a unified national health structure, based on the decentralized District Health System and Primary Health Care Approach as promulgated in the Declaration of Alma-Ata in 19782. Emphasis is placed on essential healthcare services, easily accessible to places of residence, and referral to higher levels of care as required.
Local government structures provide primary and preventative healthcare services, whilst provincial departments of health deliver the bulk of curative and in-patient care, and the national department of health sets healthcare policy. Comprehensive basic healthcare services are provided universally for free at all primary healthcare clinics (however certain disease programmes such as HIV and TB maintain separate funding streams), whilst services at district hospital level and upwards charge a sliding-scale fee based on patient income levels. Since 1994, the private healthcare sector has grown exponentially. Of the population of approximately 60 million people, only 16% of the population have medical insurance, which allows access to the high-cost private healthcare sector, whereas 84% of the population rely on the public sector3. Healthcare expenditure per capita is four times higher (R17 225 vs R4 480 in 2019) in the private sector than the public sector4.
Integration in the South African healthcare sector thus primarily focuses on the integration of the private and public healthcare sectors, by development of a National Health Insurance, which will ‘serve as the single purchaser and single payer of health care services in order to ensure the equitable and fair distribution and use of health care services’ in the country5. There is also a focus on integration of referral networks between referral levels, and integration of silo healthcare programmes into comprehensive healthcare services for users, especially at primary healthcare level.
Although the Department of Health’s National Strategic Plan6 (2021-2025) mentions that one of the main elements of healthcare system design should be ‘value for money’, this is defined as the economic and efficient provision of healthcare services in order to give citizens the best value for money, with no mention made of healthcare outcomes. And although the private healthcare sector is assumed to provide better quality of care, the recent Health Market Inquiry into the state of private healthcare provision and financing in the country7 noted that there was ‘no standardised means of measuring and comparing quality of healthcare services or outcomes’ in either the public or private healthcare sectors. Although the inputs to healthcare are measured in terms of expenditure per capita, the outputs are not, making determination of value difficult.
Thus in South Africa, although integration of both the public and private healthcare sectors is very much a national strategic objective in order to enhance the equity of healthcare provision and the quality of citizen’s lives, the ultimate goal of improving healthcare value will require greater transparency of healthcare standardisation and outcome measurement, in order to be realized.
United States of America
In the United States, while the terms integration and value have been used for decades, there persists wide variation in how these terms are used. Each term may mean something quite different depending on which sector of healthcare you ask. Nick Goodwin sites different perspectives of integration stating “a health system-based definition is integrated services: health services that are managed and delivered so that people receive a continuum of health promotion. A manager’s definition is a process that involves creating and maintaining over time, a common structure between independent stakeholders. And a patient perspective is that the patient can plan their care with people who work together to understand me and my care, allow me control, and bring together services to achieve outcomes important to me. 1 ” Common to each of these definitions is the attempt to arrange the care model to meet the needs of the patient.
Each perspective accomplishes this through a different lens, but each are attempting to drive integration to better serve the consumer and to drive value. Initially these drivers were largely financial, as payors applied pressures to healthcare providers to seek efficiencies and lower cost. What is now becoming increasingly important is the shifting of mindset to integration being for the consumer because the consumer is now, more than ever, in the driver’s seat. A consumer can shop around for their healthcare to find the best value from their perspective. Moving into the future this ability for consumers to drive decision making will only increase. Thus the patient’s perception of value will drive their decision making.
As for the term integration, the term “value” has had many meanings in healthcare. The most traditional value equation was that Value = Quality/Cost. This has shifted to be more inclusive and now is frequently stated as Value = (Quality*Experience)/(Direct + Indirect Cost). In the United States, we fall woefully short of creating value. In fact according to the Commonwealth Fund Report, the United States spends more on healthcare as a percent of GDP than any other country and yet we have some of the worst results among industrialized counties in infant mortality rate, adults with at least two of five common chronic conditions, mortality rates in conditions amendable to healthcare, and the shortest life expectancy amongst the compared group of countries for people aged 60.2
There are many speculations of why this lack of value persists in the United States. I would submit it is because we focus and misinterpret the very first part of the value equation. We put so much emphasis on “quality” that we are willing to forego the other parts of the equation. It is imperative that we move closer to fulfilling the value equation in the United States. We must be a better partner with our patients by understanding what value means to them. A collaborative approach to understanding what a good experience looks like for every individual, transparently discussing cost differences, and setting clear goals for the patient, especially at end of life, will improve the value of our health delivery system. Better including our patients and reducing complexity in healthcare in the U.S., may help us improve our status in comparison to other industrialized countries.
The concepts of integration and value appear to have different emphases in countries with differing cultures, historical trajectories, access to resources, socio-economic contexts and burdens of disease. Although all countries reviewed are grappling with the concepts of integration and value, none are satisfied that their respective healthcare systems are fully integrated and are delivering the highest potential value to patients. Factors which appear to be influencing the concepts of integration and value in the different countries appear to be differences in;
- Historical power relationships between the private and public healthcare sectors
- The complexity and multiplicity of structures delivering healthcare within countries
- The relative agency and expectations of purchasers, providers, and patients
- How healthcare services are paid for in each country
- How healthcare quality is measured and understood
- Whether quality healthcare outcomes are incentivised
- Which entities are responsible for driving and implementing change
There are numerous differences according to the above parameters. All countries reviewed are in the process of better defining and realising these concepts in order to more efficiently provide quality healthcare outcomes to a greater number of satisfied patients, and there is much benefit to be derived from investigating universal strategies, which may allow this to occur in all countries, despite our differing circumstances.
Introduction & Conclusion
1 Value as key concept in health systems https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5367583/
2 Defining Healthcare Value https://bhmpc.com/2014/06/defining-healthcare-value/
3 From Value for money to Value based health services in the 21st Century https://www.who.int/choice/publications/vbhs.pdf?ua=1#:~:text=A%20health%20care%20system%20that,informed%20decisions%20to%20use%20resources
 https://www.health.gov.au/about-us/the-australian-health-system. last accessed 24 Jul 2021
2 Australian Institute of Health and Welfare 2018. Australia’s health 2018: in brief. Cat. no. AUS 222. Canberra: AIHW.
3 Queensland Clinical Senate – Meeting Report March 2016. Available at: https://www.health.qld.gov.au/__data/assets/pdf_file/0028/442693/qcs-meeting-report-201603.pdf Last accessed 24 Jul 2021
4 https://www.choosingwisely.org.au/what-is-choosing-wisely-australia Last accessed 24 Jul 2021
5 https://www.safetyandquality.gov.au/standards/nsqhs-standards Last accessed 24 Jul 2021
6 Berwick, D.M., Nolan, T.W. and Whittington, J. 2008, ‘The triple aim: care, health, and cost’, Health Affairs (Project Hope), vol. 27, no. 3, pp. 759–769.
7 Productivity Commission 2017, Integrated Care, Shifting the Dial: 5year Productivity Review, Supporting Paper No. 5, Canberra.
8 Trankle, Steven A et al. “Integrating health care in Australia: a qualitative evaluation.” BMC health services research vol. 19,1 954. 11 Dec 2019
1 Porter, Michael E., and Elizabeth O. Teisberg. Redefining Health Care: Creating Value-Based Competition on Results. Boston: Harvard Business School Press, 2006
2 Teisberg, E., Wallace, S., & O’Hara, S. (2020). Defining and Implementing Value-Based Health Care: A Strategic Framework. Academic medicine: journal of the Association of American Medical Colleges, 95(5), 682–685.
3 Gröne O, Garcia-Barbero M; WHO European Office for Integrated Health Care Services. Integrated care: a position paper of the WHO European Office for Integrated Health Care Services. Int J Integrated Care. 2001
4 Atefa Shah, Value-based healthcare: A global assessment The Economist Intelligence Unit Limited 2016
5 Konrad Henning, Where is the money going missing in health care?, Forum Law for Growth, April 2020
8Assumptions to the Strategy of the National Health Fund for the period 2019-2023, National Health Fund https://serwisy.gazetaprawna.pl/zdrowie/artykuly/8214153,ustawa-o-jakosci-w-opiece-zdrowotnej-niedzielski-prezentacja.html
1National Health Act of South Africa 2003. Parliament of South Africa https://www.gov.za/sites/default/files/gcis_document/201409/a61-03.pdf
2 Declaration of Alma-Ata https://www.who.int/docs/default-source/documents/almaata-declaration-en.pdf?sfvrsn=7b3c2167_2
3Ataguba. National Health Insurance. Lecture
4Section 27 Fact Sheet Funding the Right to Health 2019 General Election Brief. NGO. http://section27.org.za/wp-content/uploads/2019/05/2019-IEJ-S27-Health-Fact-Sheet.pdf
5National Health Insurance Bill. Parliament of South Africa. https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf
6South African National Department of Health National Strategic Plan 2021-2025. http://www.health.gov.za/wp-content/uploads/2020/11/depthealthstrategicplanfinal2020-21to2024-25-1.pdf
7Health Market Inquiry Executive Summary. https://www.hfassociation.co.za/images/docs/HMI_Executive-Summary.pdf
United States of America
1Goodwin, Nick. “Understanding Integrated Care.” International Journal of Integrated Care, vol. 16, no. 4, 2016, doi:10.5334/ijic.2530
2Schneider, Eric, et al. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Heath Care, 14 July 2017.