During the year-long debate over health care reform, removing barriers to clinical integration received far less attention than it should have. It was preempted by debate over more voluble issues like single payer options, individual mandates, and filling donut holes. Now that attention has turned to making health reform-officially, the Patient Protection and Affordable Care Act of 2010-work for patients and caregivers, the issue is getting the attention it deserves.
Clinical integration is another way of talking about teamwork: hospitals, doctors, nurses, and other caregivers working together to provide the right care at the right time in the right setting. While the notion of working together seems unremarkable, our current health care system is built on a system of nearly unbridgeable silos, where hospitals, doctors, nursing homes, social workers, physical therapists, and other caregivers work and bill separately. So, instead of a continuum of care best suited to a patient's needs, each silo looks to do the best it can with the particular segment of care it controls.
The new law takes aim at these silos through a "a robust set of delivery system reforms aimed at incentivizing physicians, hospitals and other providers to modernize the delivery of health care by pursuing collaborative models and different cooperative arrangements to promote high quality, patient-centered care." The reforms they refer to are wide-ranging and include a Medicaid global payment system demonstration, an accountable care organization program, medical "homes" for Medicaid patients with chronic conditions, and a Center for Medicare and Medicaid Innovation charged with finding and testing innovative payment and service delivery models.
In a recent Washington Post editorial, the new Centers for Medicare & Medicaid Services chief, Don Berwick, reinforced the collaborative nature of health care reform: "[It] will help us pay for quality outcomes, not volume, with innovative tools such as bundled payments, incentives for hospitals that prevent readmissions, and accountable care organizations in which health-care providers who work in teams deliver better care with lower costs."
But bridging silos is no easy task. It requires both a cultural shift among caregivers too used to working independently, and coordinated efforts by at least five different federal agencies to overhaul a legal and regulatory system predicated on maintaining silos and punishing deviation.