Why we need a ‘big tent’ approach to healthcare integration

It’s time to broaden our definition of healthcare integration to include different constituents with different roles and different ways of interacting.

For many, the term healthcare integration evokes an image of physicians and hospitals working closely together, with a common EHR, to minimize transaction costs and provide the best combination of inpatient and outpatient care. For some, the idea evokes an image of payers, health systems and physicians aligning incentives to reduce costs. For still others, integration evokes an image of many hospitals and physicians collaborating to cover a large geographic area, with the most quaternary procedures concentrated in one place and with more common cases spread conveniently across the service area.

There has been much discussion about the opportunities and achievements of the classic integrated delivery system (IDS). But whatever views one might have about healthcare integration, it may be time for a new perspective. We propose the concept of a “big tent,” with many players under the tent carrying out a broad array of services, with a diversity of business models, for the benefit of a diverse population.

Elements under the big tent

Conceptually, this inclusive approach in healthcare encompasses many different elements:

• Behavioral health and social determinants of health
• Electronic means of communicating and addressing healthcare needs
• Venues where entrepreneurs can interact with traditional sellers and buyers of care
• New structures for dealing with issues closely related to healthcare, such as housing and access to transportation
• New forms of financial and strategic alignment

Further, the leaders who deal with all these issues need to recognize each other and coordinate efforts more effectively.

Healthcare’s big tent also is characterized by many different types of organizations and cultures. For example, in the same place where a health system stands as the largest and most stable pillar and where commercial payers are listening to calls to change under the threat of being replaced by a public option, there also might be entrepreneurs who hope to go public one day and social services providers that hope to keep their doors open another year. The big tent is home to national organizations, unique local organizations, governmental entities, philanthropies and other healthcare players large and small.

A space for new ideas and new partnerships

In some communities, elements in the big tent are working together on issues impinging on healthcare. In Nebraska and Colorado, they are coming together to address workers’ housing.^[1] In Florida and Texas, they have been together on disaster relief.^[2]

Many states have overall strategies for low-income housing, homelessness and disaster relief that go well beyond their integration and coordination in healthcare. In some communities, a single set of providers serves everyone from the homeless and Medicaid and Medicare recipients to commercial plan members and concierge patients. Conversely, in other communities, the providers that serve these different population segments don’t even know each other.

Big tent pros and cons

The advantages of this type of an approach are large and compelling. There are substantial opportunities to leverage sources of funds (Medicaid, Medicare, commercial payers and health system investments of time and dollars) more effectively in the overall financial model. The outcome of this sort of coordination can include significantly lower total costs of care.

The biggest challenges come with the time and focus required to develop joint approaches and to accommodate differences in organizational cultures and decision-making. Managing across different cultures is not easy, given the differences that often exist among the cultures of entrepreneurial organizations, local governments, academic health systems and physician practices. Cross-cultural, cross-legal management is an art form, and as the successful artists emerge, there will be much for others to learn from them.

If one considers the pros and cons together, the obstacles are not insignificant, but they are dwarfed by the potential gains.

Next steps for advancing the big tent

There are many ways of building a more inclusive approach in today’s healthcare environment. Here are some examples:

Identify common opportunities and the players that should be involved. Health systems and policymakers can promote the wide range of opportunities for new forms of integration. In some states, for example, they can build on current healthcare associations, colloquiums or philanthropic initiatives. In others, healthcare leaders can join and expand existing efforts in nonhealthcare areas, such as housing or social services.

Develop an initial strategy and financial approach. In most instances, the initials steps in developing a big tent strategy will include identifying needs, inventorying existing initiatives, understanding gaps and developing priorities. 

An effective early step is to rough out an overall financial plan. Often, dollars from one source can be leveraged to promote strategic initiatives also funded by another source. This approach tends to produce not only a more cost-effective result, but also a much closer relationship between the leaders of the different types of organizations.

Focus on behavioral healthcare. Behavioral healthcare is an area rich in potential for big tent initiatives. In most instances, health systems and/or health plans will take the lead on strengthening the integration of these areas under these more inclusive initiatives. The total costs of care can be reduced if the patients who are in need of behavioral health assistance receive it in the right form at the right time and the right place. Ensuring such an outcome benefits not only patients, but also health plans and employers, as well as social services organizations and the public entities that fund them.

One of the most efficient ways to ensure patients receive the behavioral healthcare they require is to link it with physical healthcare through primary care physician practices, because these practices are in the best position to facilitate such integration.

Nonetheless, there is much work to be done to realize the full potential of integrated behavioral and physical healthcare. The big tent has a role to play, as do employers’ employee assistance programs and the medical home program administered by the Centers for Medicare & Medicaid Services. But these are small efforts compared with what’s needed.

How big tents differ

 These inclusive approaches differ in how they are organized and who leads them. Many begin as a collection of smaller tents. For example:

• Two accountable care organizations agree to share many elements of social support infrastructure.
• Three health systems form an infrastructure joint venture.
• All health systems within a state plus several other groups agree to work together on a range of issues, including homelessness and healthcare quality measures.

Whereas the classic healthcare IDS includes hospitals, physicians and payers under a single ownership, the typical big tent includes many forms of legal entities, whether public, not-for-profit or for-profit. Yet they must address the same fundamental issues as classic IDSs, including:

• Aligning incentives
• Managing financial flows
• Designing and implementing governance and decision-making structures (including joint governance)
• Providing leaders with training
• Monitoring success

The case for a big tent

In the U.S healthcare environment today, a broad approach, involving a range of entities under a big tent, makes sense. It allows for flexibility and adjustments to local circumstances that make it possible to accomplish more in a way that is more cost effective and lowers a community’s total cost of care. The big tent is a logical next step in integrated healthcare. 

^[1]  See, for example, Purvis, J., “Blueprint Nebraska ‘a roadmap to the future,’”  Scottsbluff Star Herald, July 30, 2019.

^[2]  See, for example, Razdrih, M.S., “Anheuser-Busch, American Red Cross team up for hurricane relief,” FLAPOL, Sept. 1, 2019.