Accountable Care Organizations (ACOs)

Actually; Accountable Care Organization has emerged as a delivery model of integration to support and promote the integration process between medical partners and for example Kaiser’s permanents considered the most successful and integrated care widely known ever. the level of integration is completely differs depending on how far all integration parameters compatible together to produce one package integral system. up or down is not impossible with training to remove obstacles face current systems to be better integrated. ACOs is form of integration should be accountable for care costs and quality of certain community.

ACOs is overall accountable system working with different institutions at the same time to serve and introduce high quality value to an end user with cost control with parallel development. it should provide and manage patient care cross different service providers including out-patient services as ambulance, home visits and analysis. also in many cases care with in-patient services and post-acute cases in order to minimize branched expenditures among different service providers.

Planning and budget control is one of work target and final goal for this form of integration; try to remember one of the main integration object to minimize the expenses and that crucial for appropriate integration. In many present example of integration on purpose have leaded to increase revenue by increasing the volume of services and as a result end receivers found high cost of medications. This rising put the whole system on the fire and involved workers live in big bubble of expenses with moving fixed funds within closed system that why difficult to access and healthcare systems in some countries. 

Building system support leadership and accountability is characteristic features of this form of integration.  If we talking about firm working system; have to exaggerate leadership and empower among medical workers and support them to take the responsibility to achieve. Moreover; the government does strong share to form proper management hierarchy to create the atmosphere which play a role toward proper integration.

Observation of budget and outcome of care that enable to find out early where the defect and alternate with good accepted solutions in complied with formerly planes. these data should be examined regularly with focusing on cost/quality relationship and make feedback comparison with public could easily measure level and degree of quality achieved with demanded needs of patients.

In high advanced theories of integration says that diagnostic services emitted toward certain category of patients to register statistics significant and clinically differences between individuals in order to translate the variances between needs and necessary from desired performance benchmarks.

The integration of medical delivery system is main target for many parties that could serve governments, hospitals, researchers, insurance market and future plans of the state and forming infrastructure future needs to support conversion process from traditional to integral model which mostly important throughout whole articulation. That make data modelling and analysis more fit to focus on outcome of care with minimum level of effort. Full health J

Characteristics of a Fully Integrated Delivery System

After our talking to describe forms of integration of medical system; would like to review main and acceptable integration characteristics(Domains) have put by America’s Essential Hospitals as follow:

Component of fully integration health system;

Domain 1: Value-Driven Governance & Leadership:

Ø  The board is very focused on integration and reflects all relevant stakeholders.

Ø  Administrative leadership is very committed to promoting and implementing integration.

Ø  Physician leaders are very committed to promoting and implementing integration.

Ø  The organizational structure is very favorable to integrated care.

Ø  Strategic, financial and operational planning toward integration is very clear and convincing.

Ø  A culture of safety and teamwork is continuously taught and reinforced.

Ø  Financial, quality and community benefit data are transparent throughout the organization and to the community.

Domain 2: Hospital/Physician Alignment:

Ø  The system has a clear and convincing approach to aligning and integrating clinicians with hospital administration.

Ø  Physician leaders frequently represent the interests of all system physicians.

Ø  Physicians and administrators frequently participate in joint decision making.

Domain 3: Financial Integration:

Ø  The system is well-prepared for assuming risk-based payment and has conducted considerable analysis of the implications.

Ø  The system has a very good ability to manage contractual relationships with payers with sufficient staff/resources and compatible information systems.

Domain 4: Clinical Integration/Care Coordination:

Ø  The system provides or contracts for the full range of services and sites of care needed to meet patient demand for preventive, ambulatory, acute, post-acute and behavioral health care.

Ø  Strong evidence exists of accountability, peer review and teamwork among providers.

Ø  Care is frequently delivered at the most cost-effective and appropriate setting.

Ø  Transitions and handoffs between settings are effectively managed and need little improvement.

Ø  Strong collaboration exists between the hospital system and social services.

Ø  The system has almost fully integrated behavioral health programs into primary care.

Domain 5: Information Continuity:

Ø  Electronic Health Records (EHRs) for each patient are accessible to all providers within the system and most community providers outside of the system.

Ø  The EHR system can track all patient encounters and combine all data to system wide level for evaluation and benchmarking.

Ø  EHRs can track health outcomes of patients with specific conditions within all physicians’ panels.

Domain 6: Patient-Centered & Population Health Focused:

Ø  The system has very good, complete data on sociodemographic, utilization, cost and health status characteristics of the populations it serves.

Ø  The system’s resources and services are well-matched to the needs of the populations served.

Ø  The system provides significant social services to assist patients in accessing needed care.

Ø  The system provides almost full or full, 24/7 access to care via phone, email or in-person visits.

Ø  The system has trained all or nearly all staff in cultural competency skills.

Ø  All providers have been trained in encouraging expanded patient/family/caregiver roles in decision making and self-management.

Domain 7: Continuous Quality Improvement & Innovation:

Ø  The system frequently trains/develops employees to be future leaders.

Ø  The system frequently tests strategic activities through pilot projects

Ø  Staff feel very empowered to innovate.

Ø  Providers frequently employ evidence-based practices.

Integrated Delivery System (IDS) Payment Models

After enumerating the sorts of IDS and organization models of integration, the posts context has leaded us to the point of payment terms within integration frame work of medical system. payment pathways starting from working accounting and funds movement among providers and state institutions figure the final result of whole processes of integrations from design till execution. Honestly; it is not easily matter at all, that if controlled properly could save a lot of effort later in order to correct human mistakes and keep all medical delivery system automated without interruptions.  In coming lines; we going to discuss few various payment options ranging from shared savings to full capitalization.

Shared Saving: to exaggerate collaboration between different medial system& partners; provider, funders (insurance) & receivers. Saving strategy is one of most old and effect one; produce high responsiveness among patients and also restrict widely expenses current of useless purpose. Frugal strategy among medical workers provides the organization with two main rewards; first create awareness that expenses must be under control and that important if workers do not feel the importance how they cut excess expenditures? Second; decrease hospitalization rate and improve out-patient service through put the demanded services on borders; means the provider will never offer unnecessary services because he will lose this money with insurance firm if could not provide the prove that was in need to the patient.

Blended Payment for Primary Care: is different methodology of payment be applied with additional services provided by healthcare providers such as; care coordination, health information technology, communication and remote monitoring. Blended payment method enhance payment tool for medical home care and practices per member/ per month management fees. In addition to lightens regular visits of providers and open new resources for funding with additional value provision.

Episode-Based Payment: is way of payment of care over a period of time; means takes longer than only single visit or hospitalization. this method of payment unlike pay-for-service; strengthens the coordination and efficiency between healthcare involved partners and doesn’t depend on solitary procedure. Episode-based payment categorized into:

Ø  payment for acute care episodes that include hospital services only

Ø  payment for acute care episodes that include both hospital and physician services

Ø  payment for chronic care episodes that include outpatient care only, such as diabetes care for 1 year

Ø  payment for chronic care episodes that include outpatient plus inpatient care

Bundled Payment: is a means of payment to physicians and hospitals through one provider, multiple kind of services can be bundled and delivered by one provider. In deed this method of payment widely used in Medicare& Medicaid centers in US. Bundled Payment method encourages physicians, nurse, medical care providers to work utmost together to improve care quality to end receivers.

Capitation or Global Payment: also called full capitation, global per-member, per-month payment through capitation contract; each physician receives certain amount of money per patient on the base pay for-performance (Crosson & Tollen). This means of payment shifts the financial risk to the providers that will not paid for extra or additional services unless basic ones not in appropriate way. Global payment care mostly measures service quality to incentive the process of improvement and development among medical providers and resists against underutilization. There is no incentive to increase revenues by increasing volume of services. Full health J

Organization models of integrated delivery systems

Importance of integration of medical systems have been mentioned in more details in formerly posts and how far that reflect and carrying direct impact whether on the medical providers (horizontal) and also with patients themselves(vertical). The level of integration in deed determines the main guide lines in state medical strategies and also measure the degree of satisfaction toward value receivers. Moreover; as much as level of medical system integration appeared easy and comfortable step to the public, as much as highly effectiveness and responsiveness emerged. Different sorts of integration explained that work should be implemented among whole operational unites and processes between work axis to facilitate appearance of multiple services channels in front of patient.

Organization model of integration forms double face battle in work field; carried out many pathways to create more integration at the same line of services. these additional form of organizational integration increase complexity of healthcare delivery system and form multiple layers of integrations.

Model (1) of IDS; multispecialty group practice (MSGP) with a health plan, in which would act as a payer also so, they work provider and payer. Physicians play a role in strategic planning. collection and integration of data exaggerated more with higher level of data utilization and reviewing. main features of model cost- control capacity and lowest rate of duplication of services in certain cases.

Model (2) is an IDS or MSGP single-entity delivery system that does not own a health plan.

Model (3) involves private networks of independent providers that share and coordinate services. These networks have infrastructural services (e.g., performance improvement and care management). there are many other integrated articulations under this model include:

ü  physician-hospital organizations

ü  management service organizations

ü  group practices without walls

ü  individual practice associations

ü  "delegated mode" health maintenance organizations

Model (4) includes government-facilitated networks of independent providers on both level of state and local. Government takes the responsibilities of provider independency to deliver the medical services for beneficiaries. This model exposes a state and government setbacks and infrastructural shortage or deviations hidden.

Briefly, we show different organization working model closely touched to Integral delivery systems and also before to forget to mention that within each of them wide possibility to adapt, modify, reconstruct or create new delivery organization models in order to service new life styles have emerged recently and achieve medical welfare for whole citizens throughout community. Full health J

Horizon and Vertical Integration

The integrated delivery systems encompassed two main types of integration whether vertical or horizontal. Therein; would like here to bring your attention to may the integration can be occurred at the system level or across a patient population. the degree of integration up or down differs according to market and working realities as number of services provided through integration system or/and sort or nature provider assimilation.

Horizontal integration is defined by the Pan American Health Organization as’’ the coordination of activities across operating units that are at the same stage in the process of delivering services.” Horizontal integration involves grouping organizations that provide a similar level of care under one management umbrella. It usually involves consolidating the organizations’ resources to increase efficiency and utilize economies of scale. Example of Horizontal integration;

ü  Multi-hospital system

ü  mergers

ü  strategic alliances with neighboring hospitals to form local networks

That for sure provides a society with good prestigious hospitals running under one management and protected by state law keep providers focusing on service provision and how to improve themselves to get their reimbursement according to pay for service business model former discussed. Therefore; that open good opportunity to improve financial and working situation may be was fit or on awaited level.

Vertical integration is defined by the Pan American Health Organization as “the coordination of services among operating units that are at different stages of the process of delivery patient services. Vertically integrated systems are intended to address the following:

Efficiency goals:  

ü  manage global capitation

ü  form large patient and provider pools to diversify risk

ü  reduce cost of payer contracting

Access goals

ü  offer a seamless continuum of care

ü  respond to state legislation

Quality goals

The core of difference between vertical and horizontal integration has lied in level of service provision; horizontal integration provides similar level of care under one management umbrella while vertical integration involves group organizations provide different level of care under one management umbrella. this kind of integration produce alliances with: physicians, hospital, service management facilities, academic medical centers, long term care facilities and home care facilities and numerous services could enhance health welfare of society. full health J

Integration of medical systems

When we start talking about integration in healthcare system, to reach maximum integrity with efficient working pattern to get high achievable goals and serve broad segment of society. At first glance there are many of integration forms and working designs that was adapted to be more close for innovated medical solutions. The concept of the IDS emerged first time in 1990 in response to rapidly reimbursement environment changes. First trial carried many gaps between physicians and missteps among medical workers that leaded to high cost of introduced services with less effective role among patient and receivers. Currently there is renewed interest of IDS as a mean of cost reduction tool and overcome new cascade of services and patients demands.

In order to reduce costs; medical workers need payment system depending on value (quality& cost) rather than volume. Most of patient direct payment through provider should be fallen in one main gate better than be scattered among medical service unites and insurance firms. There are more than 70 term related to healthcare integration and 175 concepts or definitions. In order to show the evidence that there is no one declared or agreement much closely to IDS, take a look below;

ü  Integrated health services

ü  Integrated delivery network

ü  Integrated healthcare delivery

ü  Organized delivery systems

ü  Integrated health organization

ü  Clinically integrated systems

ü  Organized system of care

ü Accountable care system (ACS)

Varied definitions of IDS;

An organized, coordinated and collaborative network that: links various healthcare providers, via common ownership or contract, across three domains of integration – economic, noneconomic, and clinical – to provide a coordinated, vertical continuum of services to a particular patient population or community and is accountable both clinically and fiscally for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. (Enthoven 2009)

A delivery system which “provides or aims to provide a coordinated continuum of services to a defined population and are willing to be held clinically and fiscally accountable for the outcomes and the health status of the population served. (Lega 2007)

An organization which “uses corporate structure, strategic alliances, governance, management approaches, culture, financial practices, clinical information systems, and other tools to facilitate and insure delivery of this type of care.

(Moore& coddington 2008)

The management and delivery of health services so that the clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.                                                                                                                  

(WHO Definition of IDS 2008)

Integrated delivery system effect

on cost& quality

The integration between delivery system and cost quality axis gained significant interest recently not only as a way of modern delivery tool for end value receivers but also academically portrayed form of delivery pattern. The feasible modern healthcare system should carry certain characteristic features acclimatized with costs and demanded end value in proper quality level. Complexity, fragmentation, costly with considerable variation of care quality to satisfy different society segments. a word integrated means unite formed from other working unites and form bigger or main work providing services current and supposedly fit with fund, cost and quality. This issue if written here in simple words but actually on the ground little harder to get optimistic pictures of all parameters without setbacks.

Many healthcare policy experts addressed integrated delivery system (IDS) as a proper approach may be better in order to define quality& cost. Moreover; the academic researches and working system trials did not systemically find evidence describes the tangible relations features between them. Therefore; the question here; is there direct relationship between cost and quality, and that possible to provide high quality services with down holding costs? From study to many healthcare systems and service providers could not find direct effect on quality through expenses and cost but actually after certain cost threshold the link going reverse proportional and that neither in patient side for sure nor also achieve quality standards needed.

To prove our talk simply without deeply in system design and processes implementations; US medical system whether medicare & Medicaid could not achieve minimum level of medical safety and as a result there are many thousands living without any medical insurance Although medical US system fund and costs the most globally.

Gallup estimated in July 2014 that the uninsured rate for adults (persons 18 years of age and over) was 13.4% as of Q2 2014, down from 18.0% in Q3 2013 when the health insurance exchanges created under the Patient Protection and Affordable Care Act (PPACA or "Obamacare") first opened. The uninsured rate fell across nearly all demographic groups.^[*]

Integrated healthcare system is much complex and form patient-centric gate to provide numerous medical services with les effort and more adaptable needs. Integrated system categorized into:

-an original structure that managed by financial entity.

-an organized healthcare delivery system that coordinate care& have an IDS must possess.

In deed; the integration of healthcare systems in one main one supposed to decrease expenses and costs regularly because that shortens service processing gain steps but most of authorized political expert claim the opposite so, where the truth?

Actually all researches and studies prove that medical system integration decrease consuming funds and regularly decrease operation costs and expenses without decrease quality norms but claiming high cost and expenses from some governments just to keep expenses level higher or at the same level in order to get unclear financial targets to some countries put big question mark. Full health J