In the US, medical care receives 95% of all health funding, but only accounts for ~ 10% of our health. Among patients with key health conditions like diabetes, hypertension and COPD, the proportion of patients who get recommended care is 45 to 65%. One of the ways to get healthcare funds to pay for at least a part of prevention and care in the community is through integration of healthcare services. Another factor in fragmentation of healthcare is competition that can result from separating hospitals and different physician practices.

Integrated healthcare systems integrate healthcare facilities, physician groups, and sometimes insurance plans so that they serve as a ‘one-stop shop’ for patients. They are capable of eliminating waste, and effectively aligning provider incentives to achieve higher quality patient outcomes, better patient safety, enhanced patient satisfaction, and at lower costs. Best examples of integrated healthcare systems are Kaiser Permanente, Mayo Clinic and the Geisinger Health System. They are a good departure from fragmented care to an integrated system of care. They use effective communication through electronic medical records, use of evidence-based best practices, systems engineering and thinking, coordinated care and a culture of team work and collaboration. When hospitals, physician practices and insurance companies are separate entities, there is room for unhealthy competition although they are all serving patients. Per the commonwealth fund, there are six attributes of ideal healthcare delivery system: information continuity, care coordination and transition, system accountability, peer review of all providers, continuous innovation and learning, and easy access to appropriate care.

Integrated health systems may be either partially integrated or totally integrated. The partially integrated model is otherwise known as a shared accountability organization. In this model, the hospitals are integrated horizontally, and the physician groups belonging to different specialties are integrated together and these physicians practice at multiple locations. Many academic medical centers and some traditional health maintenance organizations are examples of a partially integrated healthcare system. In a totally integrated model, each patient has a primary care physician, all aspects of health are attended to, care is coordinated and managed, and quality and safety are assured. It is a patient-centered, coordinated, and comprehensive system of both outpatient and inpatient care, with a unified ownership, management, and operation. Less than 30% of all US providers are in such a system. The physicians and hospital form one legal ownership, governance, and operational entity. There is common management of services, common QI activities and there is alignment of financial and quality goals. Examples of successfully integrated systems are Cleveland Clinic, Geisinger Health System, Intermountain Health system, Kaiser Permanente, Mayo Clinic and Virginia Mason Medical Center.

Totally integrated healthcare systems have several advantages that include an uncompromising patient focus, major opportunities for enhanced quality and value with improved outcomes of care, patient satisfaction and safety, staff satisfaction, lower costs, and strong appeal for most health care staff. A major disadvantage is that sometimes it takes several years to develop trust between different physician practices and also between physician practice group and hospitals. Developing a unified culture can present challenges. Regulations can become more complex. Healthcare can be reformed better through totally integrated delivery systems rather than as fragmented systems, through shared core values. Once hospitals and physician groups and hopefully insurance plans unite, the entire focus can be on the patient.