Local public health integration efforts progressing, but lack resources

The increasing number of integrated health systems mostly includes commercial organizations, but integrated public health systems are necessary to provide quality care to patients relying on a safety net, according to research published in the August issue of Health Affairs. Their investigation of 10 California counties that have attempted to integrate safety net healthcare services offers a glimpse into what healthcare will be like when millions join the ranks of the insured and payment reforms begin taking hold.

In 2007, the Health Care Coverage Initiative (HCCI) began operating in 10 California counties with Centers for Medicare & Medicaid funds obtained by the California Department of Health Care Services. The program, which required participating counties to expand existing safety-net provider networks and assign enrollees to medical homes, covered a total of 236,541 people. While participating counties weren’t required to meet the ideals of an integrated system, each delivered components of the five features of an integrated system: access to care, coordinated care, electronic patient health information (PHI), quality improvement and financial incentives.

Researchers led by Nadereh Pourat, PhD, director of research at the University of California, Los Angeles' Center for Health Policy Research, attempted to assess HCCI’s success in these five areas through surveys and interviews with county public health officials.

Counties didn’t necessarily attempt to achieve these features in similar manners. For instance, to increase access to specialty care, one county focused its efforts on obtaining telemedicine grants to connect patients with specialists and another hired a recruiting firm to identify top notch specialists who were then offered leadership positions in county hospitals. The disparate approach each county took to accomplish similar objectives indicates a willingness to move toward integrated systems with local control.

“Some activities were common to all or most of the counties, such as assessing access to specialists, managing referrals, training providers in care coordination, offering disease management programs, promoting clinical guidelines, assess provider performance and promoting high quality care,” Pourat et al wrote. “These activities indicate a new and expanded role for county oversight and management of the safety net in California.”

Counties made uneven progress toward all five features of integrated systems, but progress toward increasing access to care and improving the quality of care was more easily measured and marked compared with efforts toward care coordination, increased availability of PHI and alignment of financial incentives, which were more difficult to assess.  

In some of the counties' integration efforts began before HCCI was instituted and most counties exhibited enthusiasm for integrated systems among leaders in different stakeholder communities, leading researchers to believe slow-moving progress in some areas was most likely due to the lack of resources afforded to public health departments.

“Although full system integration has not yet been achieved, county-based health systems can be viable competitors to commercial providers in the post—Patient Protection and Affordable Care Act landscape,” Pourat et al wrote. “However, extensive efforts and major resources are required. In addition, the necessary impetus for systemic integration may not be present without federal financial support and contractual agreements with state insurance exchange plans.”