Breaking Down Healthcare Silos: The Need of Healthcare Integration

dataThe American healthcare system … isn’t. It isn’t a “system.”

Patients have multiple providers. These providers rarely interact. The payment system operates in silos. And patient care isn’t coordinated.

This disjointed system is not a new challenge. In 1965, the federal government created Medicare, a program which provides coverage for certain services. Medicare Part A covers inpatient hospital services. Medicare Part B covers outpatient care like physicians’ services.

Forty years later, in 2006, the government launched Medicare Part D, which covers prescription medications. But the original Medicare program created payment and data silos for Parts A and B. Today, Medicare Part D is administered by private pharmacy benefit managers (PBMs). And the three parts (Medicare A, B and D) rarely talk to each other or share information.

So, that’s the public sector.

The payment and health information silos, unfortunately, also exist in the private sector. Most of us are covered by some kind of health insurance which pays for physicians, hospitals, and diagnostic tests like x-rays or CT scans. But our dental plan is usually completely separate. And our pharmacy program is typically administered by a pharmacy benefit manager (PBM).

This fragmentation – both healthcare services and payment – leads to many patient care challenges and conflicts. Medicare Part D plan administrators (and PBMs) are laser-focused on keeping drug costs down. As a result, they may not cover certain medications. Part D plans (and PBMs) are not impacted by – nor really care about – increased hospitalizations or more diagnostic tests. That’s not their problem. They care about keeping drug costs low. They don’t care if their decision to limit coverage of some medications results in increased physician or ER visits.
But just when we take two steps forward, we take two steps back.

Medicare Advantage plans are privately managed and provide comprehensive services from hospital care to medical care to pharmacy and diagnostic tests. These plans are integrated to ensure proper care coordination. Medicare Advantage plans have incentives to provide the best care to the patient. These plans are the two steps forward I referred to earlier.
To help pay for ObamaCare, the president and Congress cut Medicare Advantage funding by more than $700 billion. Those are the backward steps.
The future of American healthcare is the promise of integrated systems where clinicians have access to patient data and payment models to reinforce coordinated care. Integrated systems do not create or reinforce silos of care. Integrated systems destroy silos. Patient care improves as a result.

Healthcare is just like everything else. More information is typically better than less.

You wouldn’t think about buying a car without the MPG or price or warranty information.
But in today’s non-integrated healthcare system, doctors don’t know what drugs other physicians have prescribed. Hospitals don’t know what tests and procedures have been performed on us as patients. And pharmacists don’t know if a patient has multiple prescriptions from multiple physicians for multiple controlled substances.

In integrated systems, more information is better. Physicians, pharmacists and other clinicians practice to the top of their licenses. Patients receive coordinated care that improves patient outcomes. And hopefully, because of health information technology, the American healthcare system can finally become a true “system” which drives and rewards performance, patient outcomes, and efficiency.

We need to break down more healthcare silos.

3 comments Add your comment

Detria

January 16th, 2013
4:11 am

This article is very informative, however, I would like to add another piece that I see as an issue in my profession as Transitional Care Coordinator. When my client is scheduled for discharge, I have noticed a communication breakdown between patient,, family/ caregiver and where the patient is returning home. I had a situation where the family was so tired from sleeping uncomfortably in hospital recliners for days at a time, while it was touch and go for their loved one. Being exhuasted and overwhelmed can cause some problems. For example:
1. The prescriptions had not been signed by the discharge physician. The family did not notice until they were home.
2. The family did not know what medications were given the day of discharge so they had to contact hospital to find out so their loved one was not over or under medicated.
3. The assisted living facility is not equipped for two assists so the family had to hire an outside home health agency to provide around the clock care for their loved one would have to leave his home.
4. The assisted living facility did not appear to be as proactive in getting prescriptions signed by discharge physician.
The purpose of giving this information is to show another disconnect between hospital, in home care etc. There are gaps that need to be filled to help keep re-admissions down.
But hospitals and outside resources are not working together as much they could. Let us ( Transitional Care Coordinators) in by accepting our information and how we can be of service to their patients from the initial process of discharge. We see the affects after discharge, they see the patient being readmitted in less than one week.

Archie Lange

June 23rd, 2013
12:24 am

home health is of course very very important because we want to ensure that our kids and family members are disease free. ^,.-

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Vashti Chisler

June 24th, 2013
11:46 pm

Medicare offers all enrollees a defined benefit. Hospital care is covered under Part A and outpatient medical services are covered under Part B. To cover the Part A and Part B benefits, Medicare offers a choice between an open-network single payer health care plan (traditional Medicare) and a network plan (Medicare Advantage, or Medicare Part C), where the federal government pays for private health coverage. -”“

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