By Gemma Hughes, Sara E. Shaw, Trisha Greenhalgh
The Milbank Quarterly, May 20, 2020
Context: Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.
Methods: We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.
Findings: We identified four perspectives on integrated care: patients’ perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.
Conclusions: Those looking for universal answers to narrow questions about whether integrated care “works” are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.
From the Introduction
A guiding principle for system redesign is integrated care. Integrated care refers to both the methods that might be used to organize, fund, and deliver health and related services and the interrelated goals of better outcomes, experiences, and use of resources. Integrated care has been studied in various ways—for example, as an organizational and social process, as an indicator of health system effectiveness, and for its effects, such as economic impact. The result is a heterogeneous body of literature with the term used by different authors to mean different things. Most espouse “patient‐centered” goals and values. Few dispute the principle of integration. (Who would want care that is not integrated?)
To date, consistent benefits from integrated care programs have proved elusive. Despite evidence of some aspects of improvement in certain settings for certain people, expectations that integrated care programs will improve outcomes and reduce health service utilization are often disappointed.
From the Discussion
The search for integrated care is a search for unity. This applies both to efforts to integrate patient care, services, and organizations and to scholarly work to create unified conceptual models. However, we found two key tensions across the literature that undermine the idea of integrated care as a unified concept. First, we found that “integrated care” was not one empirical phenomenon; rather, it covered a multiplicity of objects, strategies, and aims. Practical efforts to integrate care were concerned with creating unity of a great variety of objects: patient care and experience, multidisciplinary and interorganizational working, and health care systems. “Integrated care” included overlapping, interrelated, and, at times, conflicting strategies and experiences. Moreover, integration was pursued for a variety of ends (eg, to both improve patient experience and to reduce hospital admissions) and meant different things to different people. Patients, service providers, and policymakers had different ideas about, and different experiences of, integrated care.
Second, we found that conceptual models of integrated care assumed alignment of patient and system perspectives and of multiple strategies into a coherent, decontextualized whole. However, the range of framings provided by scholars bringing social theory and critical analysis to the study of integrated care undermines the normative, and often deterministic, frameworks provided by unified models.
Integrated care programs are contextually shaped but have common logics. Normative models of integrated care can therefore be of heuristic value (for example, in accounting for features of successful programs), but they will inherently fall short of accounting for the intricacies of different contexts and processes. The range of theoretical framings found in this review used to analyze integrated care preclude the creation of a single explanatory model. Integrated care can more usefully be studied and understood as comprising an emergent set of practices intrinsically shaped by contextual factors than as an intervention that will achieve a predetermined set of outcomes.
By Don McCanne, M.D.
The policy community and the medical-industrial complex seem to be fixated on business models of reform rather than patient service models. “Integrated care” seems to be a common theme of theirs, though this Milbank Quarterly report indicates that there is little agreement on precisely what integrated care means.
As the authors state, “Who would want care that is not integrated?” But Kaiser Permanente as an integrated delivery system is quite different from an accountable care organization to which patients do not even realize that they are nominally assigned. Hospitals purchasing physician practices is a different kind of integration than when large investor-owned insurers assume control of portions of the delivery system. Clinics coordinating with food, housing, and transportation services is another form of integration. Private Medicare Advantage plans integrated with contracted vendors is quite different from traditional Medicare that is integrated with almost the entire health care delivery system. And so on.
The greatest problem in health care today is that, in spite of spending $4 trillion, far too many are unable to access the care they need because of the financial barriers that result from the design of our health care financing system. The solution is simple. Fix the problems that are inherent in our existing Medicare program, expand it to include everyone, and fund it with equitable, progressive taxes that will make it affordable for each of us. If you want to call that an integrated financing system then go ahead, but do not let the business interests expand control through their integrated entities that are designed primarily for business success rather than for patient service.
The Milbank Quarterly article is an open access article. You may want to read the full article as it can assist you in rethinking integrated care. Let’s get it right for the patients, not the plutocrats.
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