Horizontal Integration-Med Neighborhoods (CH 7+8)

horizontal integration

consolidation of healthcare units providing the same type of services

virtual integration

hospitals and insurers recruit office-based FFS community physicians into an IPA, creating a basis for an HMO and negotiate contracts with physicians to provide care

benefits of virtual integration

integration of services based on contractual relationships rather than unitary ownership; contracts between HMOs and physician groups, hospitals, and other provider units

disadvantages of virtual integration

governance and alignment friction (slow decision-making), IT hurdles, weaker control, variable engagement

independent practice associations (IPAs)

groups of independent physicians who contract with HMOs to provide care while maintaining their own practices; allows insurers, etc to respond to market changes by renegotiating contract bargains with providers

• has advantage of low capital costs because HMO does NOT have to own buildings

integrated medical groups

horizontally, tightly integrated medical group

integrated medical group model

physicians do not own their practices, but the medical group organization employs them

(IMGs) value of virtual integration

allows autonomous healthcare components to coordinate care and share data without massive capital expense and regulatory complexity of physical mergers/acquisitions; enhanced access and reach, streamlined care, aligned incentives

(IMGs) disadvantages of virtual integration

clinical limitations, reimbursement and licensing barriers

importance of HMO act 1973

under Nixon’s health care reform, gave federal funds to promote expansion of pre-paid practices and IPAs

• medium and large businesses had to offer one HMO plan to employees

traditional primary care model

“my pts are those who make appointments to see me” -> care determined by “today’s” problem and time available “today”, care varies by scheduled time and memory/skill of doctor, “I know I deliver high-quality care because I’m well-trained”, patients responsible for coordinating their own care, up to patients to tell providers what happened to them, clinic operations center on meeting the doctor’s needs

new primary care model

“OUR patients are those registered in our medical home”, care determined by proactive plan to meet health needs with or without visits, care is standardized according to evidence-based guidelines, “we measure our quality and make rapid changes to improve it”, prepared team of professionals works with all patients to coordinate care, track tests and consultations + follow-up after ED and hospital care, “an interdisciplinary team works at the top of our license to serve patients”

role hospitalists have in health care

a physician whose primary role is to care for hospitalized patients and return them to their regular physicians at discharge

patient care medical homes

solution for medically complex patients (high-need; chronic illness that require regular medical monitoring, advising, or treatment) where all patient needs are coordinated via a single center using bundled payments; to qualify, a practice must meet standards and be certified

• PCP is first source of contact

• Care is person-focused over time

• Comprehensive care

• Coordinated care when patients need outside specialist care

Accountable Care Organizations

network of physicians and other providers that are held accountable for the cost and quality of continuum of care delivered to a group of Medicare patients

• developed as a strategy to modify FFS payment to encourage a more integrated, population health approach

• Another form of virtual integration

• “Provider organizations contract with a payer to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population”

Medical Neighborhoods

based on patient-centered medical homes where PCP is in charge of care provided by all people and places where care is provided (specialists, pharmacies, hospice, home health, nutritionists, etc)

• services are functionally integrated (similar to traditional HMOs)

• PCP coordinates care, patients are involved and informed -> coordinated care contributes to health of a population

• High performing health care requires excellent medical homes and neighborhoods