Dr. Helmut Hildebrandt talks values, Rome-like circus arenas and business models as he sets out the five components required to replicate and transfer Integrated Care experiences.
Positive values and good arguments for integration and improvement of health and health care alone are not sufficient. Health scientists and health improvement enthusiasts in integrated care have to go further down the line towards digging into the financial incentives and structures of the health care system in their countries. Integration of health promotion, social factors and the fragmented healthcare sectors need a lot of financial investment and clear business models to refinance the investment into the improvement. With this blog I want to share some considerations on how to replicate pilot projects that may have been financed by some project money in the beginning but now are showcased for their added value and their financial benefits.
I can draw on the Healthy Kinzigtal integrated care contract that was started in 2005 and several initiatives we started with OptiMedis to replicate Kinzigtal in other regions of Germany as well in the Netherlands, UK and Belgium. Regarding the values we want to pursue with our model of integration of health promotion, social factors and the fragmented healthcare sectors, we look for the Triple Aim concept of health status improvement for a regional population. This model satisfies the needs of the population but doesn’t produce any further costs for the health care system than usual (fragmented) care (Berwick et al 2008; doi:10.1377/hlthaff.27.3.759.) and in Kinzigtal we are even able to demonstrate lower costs. We enlarge the Triple with the fourth – the quadruple aim – of health professional satisfaction (because all our goals would not be achieved if we didn’t look for the health and wellbeing of the providers as well). So far so good … and politicians, health insurers, patient organisations and a majority of health care providers feel comfortable with these aims. Problems arise when investments and money come into the game. Health status improvement may reduce the revenues of providers and their owners, however, health insurers or national health systems and physicians may not feel responsible for addressing social needs, as paying more time and attention towards health promotion may not be in the commercial interest of private practices trying to reduce the time spent with the patient, or only with significant enlargement of payments. Now many of us may feel being in a Rome-like circus arenas like in the old days of Rome having to fight and collaborate at the same time with a lot of partners and different interest-owners.
I would argue that the general model, interventions and evaluation frameworks of the OptiMedis approach (see Groene O et al, 2017 doi:10.1007/978-3-319-56103-5); like we developed it in Kinzigtal or Billstedt-Horn are widely applicable and not only in Germany. For example, all key aspects of the OptiMedis model are deeply rooted in the scientific literature and in models that have shown to be effective elsewhere, such as the triple aim approach (Whittington JW et al 2015 doi:10.1111/1468-0009.12122.31.), the chronic care model (Barr VJ et al 2003, In Hospital Quarterly), audit and feedback strategies (Ivers N et al 2012, Cochrane Database of Systematic Reviews, 6, CD000259.), the focus on patient activation (Hibbard JH 2015 doi:10.1177/1077558715573871), or pharmacological consultations to improve the safety of drug prescriptions (Phatak A et al 2015 doi:10.1002/jhm.2493). But the real question, that is finally determining the success of the model, is not the intervention but how to balance the power structure and how to develop a persistent and sustainable business model.
In order to successfully transfer and scale-up this model elsewhere, a number of learnings should be taken into consideration. Their relevance may differ depending on the health system context and the organizational model applied, but in our experience of the last thirteen years the following issues proved relevant:
- First, a key component of the triple aim model is the role of the “integrator”. In our experience, this should be a regionally-based organisation, which is familiar with local (health) service issues, that plans and delivers local intervention and maintains the communications with all stakeholders. The “integrator” needs to be managed by an organisation capable of providing investments, engaging in negotiations with high-level decision-makers, and of providing advanced health data analytics while at the same time (supported by shareholders) pursuing long-reaching value-development instead of short-term profits. This organisation may have shareholders from the local context to generate regional credibility, and it will help to have shareholders from local physician and health care networks. On the other side, physicians as shareholders may generate trust but mistrust can form between other health care professionals and social organisations. As a result, we try to experiment with different forms of shareholder agreements in our new regions like Werra-Meißner. Up to now we have no experience in local patients and care givers associations as shareholders, but would very much like to gain this experience.
- Second, during the first years, considerable start-up investment is needed to set up the organisational structures, integrate stakeholders, and to design interventions, which in turn means that appropriate funding has to be ensured for at least three years until income can generate a return-on-investment from a shared savings approach. This is because of two types of delay: a) the time lag between intervention onset and successful health improvements (at least one year) plus b) the time lag in obtaining the data reflecting such improvements (which often amounts to another year). In Kinzigtal we were able to use a certain time-limited situation within Germany that allowed for funding through the insurance companies (as a compensation we had to draw our interventions only on their insurees thereby neglecting patients from other sickness funds). In Billstedt-Horn we were successful in a bid for funding from the German innovation fund in health care, but there are some compromises in return for this funding: there are lots of bureaucratic restrictions which reduces the energy and the pace for improvement work. To engage private investment and banks in the start-up-financing will risk making compromises too, for instance what are the back-up securities for them? They will ask for clear business plans, longstanding contracts with the health insurances and quite an amount of detail about interest rates. For our third region in Germany we will be able to start with a mix of public funding and loans from banks..
- Third, the size of the population needs to be appropriate to ensure networking among providers, the identification of local solutions and the exchange of ideas amongst all stakeholders. Population sizes smaller than 100,000 appear ideal (assuming the number of stakeholders that can be managed should not exceed 100). While it may be tempting to establish much larger regions it is unlikely that the local “kit” (a common culture, mental models, mutual understanding of local issues, and trust) needed to motivate stakeholders towards a common goal can be easily established. Even then the development of a common culture is not that easy and underlies constant changes and challenges. Providers have their peers that are stuck in their different business models and thinking, staff members may have been trained not to support self-management but to “care” and maybe even to patronize patients and their care-givers, while sickness funds have regulations that may be hindering open access and sharing data and accomplished savings.
- Fourth, a comprehensive information-technology package (including digital assist solutions to patients and shared patient records) and competencies for advanced health data analytics to inform intervention planning, feedback reports to providers, and internal evaluation are crucial in order to ensure seamless care and monitor performance. As important as they are their value may not be acknowledged by everybody, internal and external evaluation and transparency may be seen as control and power, shared patient records (especially if shared with the patients themselves like in the OpenNotes model in the US) develop a different power balance between providers and patients that may not openly accepted by the providers (and may be not by the sickness funds as well). New digital APPs and solutions in telemedicine may be felt by local providers as interfering with their monopoles and thus be opposed.
- Fifth, the business model with two parts (1) a balanced payment system for all kind of providers oriented towards achieving the triple resp. quadruple aim, which is incorporated in the shared savings approach, is needed and (2) a clear outcome-oriented payment system within the shared savings model between the regional integrator and the health insurance/payor as such. The existing payment systems within the fragmented sectors produce quite a large challenge to the invention of new, somehow more health-outcome related payment systems, that are fair and bear in mind that patients of different social backgrounds and experiences may generate different outcomes. This challenge is also a hazard to the shared savings model with the sickness fund. A thorough and long-term stable model for shared savings has to take a lot of factors in account (Pimperl et al 2016 DOI: 10.1089/pop.2016.0036).
The level of accountability which allows to make decisions on how cost savings are (re-)invested is an important governing factor supporting regional autonomy. In Kinzigtal for instance, the free margin of these savings (after costs for data analysis, staff inside Kinzigtal, add-on provider renumeration) are used to reinvest in the population health management strategy, for example by constructing a new comprehensive health centre (partly supported by the cost savings), by distributing tokens to citizens that can be used to support local entities (such as schools, sports club or church entities), or by providing some additional financial incentives for good performance.
Model expansions are currently being discussed with various regions in Germany (and abroad), taking into consideration the lessons learned during the last thirteen years. We anticipate a much faster learning curve in new regions, bearing in mind that various prerequisites and interventions are ready to scale-up, such as quality indicators, evaluation protocols, programme outlines, incentive systems, management guidelines, data warehouse and reporting systems, balancing of power and shareholders etc. Nevertheless, our learnings will have to go on as mentioned in the five points above, especially towards enlarging the role of direct contacts between the regional integrator and the local population itself. Ideally, if multiple regions could be set up and implemented simultaneously, that would generate a unique source of data for advanced health analytics to further evaluate the impact of integrated, population health management systems, and moreover, to allow a systematic process evaluation of how the model could be further scaled up nationally and abroad (Ovretveit J & Klazinga N 2012 doi:10.1093/intqhc/mzs046.).
Dr Helmut Hildebrandt is the Treasurer for IFIC and Chairman of the Board of OptiMedis AG and leading expert on Integrated Care.