Purchasing population health: aligning financial incentives to improve health outcomes

Collaborating while competing? The sustainability of community-based integrated care initiatives through a health partnership

BACKGROUND

To improve health-care delivery, care providers must base their services on community health needs and create a seamless continuum of care in which these needs can be met. Though, it is not obvious that providers apply this vision. Experiments with regulated competition in the health systems of many industrialized countries trigger providers to optimize individual organizational goals rather than improve population health from a community perspective. Thus, a tension exists between the need to collaborate and the need to compete. Despite or because of this tension, community health partnerships are being promoted, and this should enforce a needs-based and integrated care delivery.

METHODS

In this single case study, we retrospectively explored how local health-care providers in Amsterdam collaborated for more than 30 years, interacting with the changes to the national health-care system. In-depth analysis of interviews, documents and literature focused on the complex relationship between the activities of this health partnership, its nature and its changing context.

RESULTS

The findings revealed that the partnership itself was successful and sustainable over time, although the partnership lost its initial broad explorative nature and narrowed its strategic focus towards care of the elderly. Furthermore, the realized projects--although they enforced integrated care--lost their community-based character. This declining scope of community-based integrated care seems to have been influenced by the incremental introduction of regulated competition in Dutch health care. This casts doubts on the ability of health partnerships to apply a vision of community-based integrated care within the context of competition.

CONCLUSION

Collaborating health-care providers can build seamless continuums of care in a competitive environment, although these will not automatically maximize community health with limited resources. Active policies with regard to health system design, incentive structures and population-based performance measures are warranted in order to insure that community-based integrated care through health partnerships will be more than just policy rhetoric.

Local health systems in 21st century: who cares?-An exploratory study on health system governance in Amsterdam

BACKGROUND

There is a growing awareness that there should be a public health perspective to health system governance. Its intrinsic population health orientation provides the ultimate ground for determining the health needs and governing collaborative care arrangements within which these needs can be met. Notwithstanding differences across countries, population health concerns are not central to European health reforms. Governments currently withdraw leaving governance roles to care providers and/or financiers. Thereby, incentives that trigger the uptake of a public health perspective are often ignored.

METHODS

In this study we addressed this issue in the city of Amsterdam. Using a qualitative study design, we explored whether there is a public health perspective to the governance practices of the municipality and the major sickness fund in Amsterdam. And if so, what the scope of this perspective is. And if not, why not.

RESULTS

Findings indicate that the municipality has a public health perspective to local health system governance, but its scope is limited. The municipality facilitates rather than governs health care provision in Amsterdam. Furthermore, the sickness fund runs major financial risks when adapting a public health perspective. It covers an insured population that partly overlaps the Amsterdam population. Returns on investments in population health are therefore uncertain, as competitors would also profit from the sickness fund's investments.

CONCLUSION

The local health system in Amsterdam is not consistently aligned to the health needs of the Amsterdam population. The Amsterdam case is not unique and general consequences for local health system governance are discussed.

Comparing health status with healthy habits in elderly assisted-living residents

There is a growing number of older adults in America. Assisted-living facilities have become a more prevalent residence for this increasing population. In the study described in this article, a secondary data analysis was completed using residents of several LifeTrust America, Inc.,'s assisted-living facilities across the Southeastern United States. There were 1,079 residents who completed the Healthy Generation Survey. Residents were asked whether they currently, previously, or had never had certain health conditions. They also responded to various questions about their current participation in healthy habits, such as using cigarette or tobacco products, moderate alcohol consumption, eating breakfast, eating healthy snacks, getting 7-8 hours of sleep each night, drinking the daily recommended amount of water, and participating in regular physical exercise. The research question asked if there was a relationship between current healthy habits and physical health. The study found that individuals with more current physical health conditions also reported greater participation in healthy habits. This could lead to the conclusion that after individuals acquired certain physical health conditions, they began to participate in more healthy habits. Also of significance was the finding that participation in physical exercise and recreational activity related to greater participation in all other healthy habits.

A classification scheme for outcome indicators

PURPOSE

To provide a framework for classifying outcome indicators for a more comprehensive view of outcomes and quality.

METHODS

Review of outcomes literature published since 1974 from medicine, nursing, and health services research to identify indicators. Outcome indicators were clustered inductively.

FINDINGS

Three groups of outcome indicators were identified: patient-focused, provider-focused, and organization-focused. Although investigators tend to focus on a select few outcome indicators, such as patient satisfaction, quality of life, and mortality, many indicators exist to measure outcomes.

CONCLUSIONS

Selecting and integrating a wide array of outcome indicators from the various categories will provide a more balanced view of health care delivery as compared with focusing on a few common indicators or only one category.