Integrated care programs and initiatives around the world are starting to demonstrate up to 30 percent reductions in health system utilisation and costs, especially in downstream facilities such as tertiary hospitals.
Integrated care is a term in vogue and has many definitions. I like the view that connecting different parts of a health system allows access to solutions that are ordinarily disconnected from where problems lie. For example, expensive downstream hospital utilisation can be reduced by pulling upstream levers in primary care, but the way we fund and deliver services in Australia limits hospital payers (State Government and insurers) from enhancing primary care (which is solely funded by Federal Government or patients). Connecting the health system may occur vertically (e.g. vertical integration of payers and providers) or horizontally (e.g. across the clinical, social, mental health and functional needs of patients). Done successfully, it enables a reallocation of the health investment portfolio to areas that deliver greatest value for the system.
In Australia, the notion of a more integrated health system is important. We have a structurally siloed system managed and funded by nine Governments, numerous private insurers, under complex funding arrangements, and delivering services to the same patient from an array of disjointed providers. Benefits that accrue from integrated care may include:
- Reduced errors. Conservatively 18,000 Australians die annually due to health system errors – that’s two typical Sydney-Melbourne flights crashing every week
- Less duplication. Example – 15 percent of Australians undergo unnecessary, repeat imaging
- Improved experience. Example – 1 in 8 patients report lack of communication between their clinicians
- Better coordination Example – one-third of patients discharged from hospital to GP or community care have a coordination gap
- Hospital avoidance. Example – GP clinical records that are accessible to emergency department staff can help avoid automatic admission for some patients
- Lower mortality. Example – Early results from Medibank’s primary care programs have one third the death rates compared to control
Integrating care along the entire patient journey allows market incentives to invest where there is optimal social and commercial return. For example, only 7 percent of our health expenditure is currently on General Practice services in primary care; the evidence for more primary care clinicians (and greater access to these clinicians) is compelling. Investing more in primary care is associated with lower all cause mortality, lower acute admissions, lower exacerbations of chronic diseases, better prevention, and better self-reported health.
It is worth looking at the international evidence for approaches to more integrated care.
- Medical Error Action Group
- AIHW Health expenditure estimates
- Commonwealth Fund
- Consumer Health Forum
- Contribution of Primary Care to Health Systems and Health; BARBARA STARFIELD, LEIYU SHI, and JAMES MACINKO