There have been a number of interesting articles we’ve read recently that promote the role of hospitals in integrated care systems originating from ‘Obamacare’ – the US reforms. These include community level clinical and social services for populations. Articles include:

And the US Federal Government has just launched:

This feels to us to be an extremely relevant approach to discuss because in the South African private healthcare sector environment there is a huge and growing dependence on hospitals and hospital beds.

Hospital services are used to address straightforward clinical problems and undertake the simplest of procedures. Weak community healthcare services are both a cause and a result of this arrangement.

Is it possible that hospitals can be part of the prudent solution where services are done in the appropriate site?

In addition, is there a model of population medicine built around the hospital that adds value to the community it serves and is also commercially profitable?  

For the hospital to be well aligned with the needs of its client population, it must get rewarded for being part of the integrated care systems. If the hospital remains dependant only on its current volume derived income rather than its population medicine mandate, the contradictions of supporting effective community services are hard to resolve.

There a quantum leap is needed, a major rearrangement of the organisational and financial relationships compared to the current.

The organisation of a system where the hospital is the hub is characterised by clinical service lines designed for identified segments of patient demand (adult chronic medicine; maternity care etc.) that extend from households in the community and free standing clinics to hospital polyclinics and then into wards and theatres and ICUs and back again – continually. The teams that service these channels are made up of multiple disciplines and are focused around the needs of each patient. As a result, each patient can move seamlessly in the integrated system, which is also supported by Care Coordinators and an IT systems to make this work.

Financial arrangements for teamwork need shared recognition and basic remuneration so that individual clinicians get rewards for the success of the team. The upside rewards are measured against the requirements of the population that they serve. This disqualifies the current ‘fee for service’ (FFS) tariff because it rewards an excess of services rather than the minimum and prudent treatment option and is therefore not in the best interests of the community.

In general, this means long term population linked fees for consulting disciplines (GPs; Physicians; Gynaes etc.) and bundled or episode fees for therapies with a well-defined beginning and end, such as elective surgery, and a mixture in between.

All of this is very relevant to the current debate about employing doctors in SA.

Proscribing the employment of doctors is blamed for some of our systems inefficiencies. We believe that simply lifting the block and allowing hospitals to put them on a salaried payroll may not be the right or only answer. If fragmented single practice is the problem, and teamwork is the answer, then a better answer may be the creation of commercially independent and autonomous teams of clinicians who work and earn together and can enter into contracts or joint ventures with both medical schemes and hospitals.

PPO Serve Integrated Clinical Consortia™ are the answer. Joint ventures between them and their hosting hospitals completes the model.


Don’t want to read the full articles? Here are summaries of the important points:

Hospitals as Hubs to Create Health Communities: Lessons from Washington Adventist Hospital

Hospitals as hubs in community services can bring effective care to people and populations:www_brookings_edu___media_research_files_papers_2015_09_health-neighborhood_hospitals-as-hubs-to-create-health-communities_pdf

They are in a position to also begin to address social determinants, which we know that when ignored invariably negate clinical gains:

  • They build community networks linked to the hospital services, which facilitate integrated clinical care and bring services closer to the home.
  • The hospital has programs which aggressively enrol discharged patients in community support initiatives.
  • They undertake specific ‘hot spot’ programmes i.e. programmes that deal with specific community or locale issues that cause healthcare problems that can be addressed if the system has a population view and mandate

They get population related rewards. This means a population related budget system with rewards related to population based performance. There are penalties for avoidable readmissions. There is a useful new US funding program called the Community Health Needs Assessment (CHNA) that provides additional financial incentives to hospitals to collect addition data upon which to base intervention programs

Clinical data sharing is key – this arrangement permits full population data exchange i.e. record of all activities that the patient experiences is available from an integrated database. This also includes non-clinical data. In addition to aiding better individual patient care, the data is used to identify and address ‘hot spots’ for management; and for risk stratification of the patients in the community in order to design and channel them to appropriate services and interventions.

Multidisciplinary team is key – clinicians and support staff work together on joint care plans and hold regular reviews of individual patients and system processes.


Can hospitals help create healthy neighbourhoods? 

Cursor_and_JAMA_Forum__Can_Hospitals_Help_Create_Healthy_Neighborhoods__–_news_JAMASome hospitals are rethink their roles in healthcare systems, not just focusing on resolving acute problems and providing emergency care. ‘Hotspot’ strategies that successfully affect local communities and initiatives to address social determinants of health are prodding the rethink.

There are also now US financial and regulatory nudges too, such as penalties for high 30 day readmission rates. The CHNA (above) requires non-profit hospitals (the vast majority in the USA) to report on their communities social needs and develop strategies.

Difficulties include information sharing because of different data systems, as well as privacy restrictions. Critically, there is a ‘wrong pocket’ problem – hospitals that invest in community partnerships can work against its own bottom line even as the community is rewarded.

Silo budgets are another issue – in SA a medical scheme cannot invest in social services that might reduce the need for hospitalisation and improve longevity that is in the interests of life insurers, even for the same lives….

The authors suggests 4 steps to achieve this reform:

  • Develop metrics to measure the social and economic benefits of hospital community work
  • Make data sharing easy
  • Blend funding pools
  • New forms of investment capital


The Accountable Health Communities Model – a CMS Innovation Center pilot project to test improving patient’s health by addressing their social needs

Cursor_and_HHS_govThis is a new funding programme for screening people about their health related social needs and related referrals can improve quality and affordability.

Many of these issues – housing instability; hunger, interpersonal violence, transport problems – aren’t revealed in the normal clinical encounter but nonetheless have significant impact on the individual’s use of the healthcare services.

The programme aims to at ‘bridge’ organisations that align clinical and community services by connecting the identified patients to services and assessing the impact that has on their use of healthcare services, especially emergency room use, readmission rates and total healthcare costs.