Health Care Delivery

Health care delivery in the United States often lacks coordination and communication across providers and settings. This fragmentation can lead to poor quality of care, medical errors, and higher costs. Providers have formed integrated delivery systems (IDS) to improve efficiency, quality, and access. The Health Care Safety Net Act of 2008 directed GAO to report on IDSs that serve underserved populations--those that are uninsured or medically underserved (i.e., facing economic, geographic, cultural, or linguistic barriers to care, including Medicaid enrollees and rural populations). In October 2009, GAO provided an oral briefing. In this follow-on report, GAO describes (1) organizational features IDSs use to support strategies to improve care; (2) approaches IDSs use to facilitate access for underserved populations; and (3) challenges IDSs encounter in providing care, including to underserved populations. GAO selected a judgmental sample of 15 private and public IDSs that are clinically integrated across primary, specialty, and acute care; they vary in their degree of integration, specific organizational features, and payer mix (e.g., extent to which they serve Medicare and Medicaid beneficiaries and the uninsured). GAO interviewed chief medical officers or other system officials at all 15 IDSs and conducted site visits at 4 IDSs, interviewing system executives and clinical staff.

IDSs in GAO's sample reported that using electronic health records (EHR), operating health insurance plans, and employing physicians all support strategies to improve patient care. An EHR contains patient and care information, such as progress notes and medications. Some IDSs said that using EHRs supports their patient care strategies such as care coordination, disease management, and use of care protocols by increasing the availability of individual patient and patient population data and by improving communication among providers. IDSs also reported that operating a health insurance plan can support patient care strategies by providing to the IDS both financial resources, such as savings from reducing avoidable hospitalizations for health insurance plan members, and data on plan members. For example, financial resources could be used to fund services such as care coordination--which many insurers do not reimburse--and the data could assist with strategies such as disease management. Employment of physicians was reported to facilitate physician accountability for quality of care because physicians who are employed by the IDS must meet certain performance indicators, and the IDSs collect data on and review physician performance. Employment of physicians was also reported to increase adherence to care protocols and to facilitate provision of care to underserved populations through compensation that mitigates physicians' concerns that they might not receive payment from uninsured patients. IDSs in the sample discussed several approaches they use to facilitate access to care for underserved populations. These approaches include using community-based settings, such as school-based health centers and federally qualified health centers (FQHC); conducting outreach; helping patients apply for coverage programs such as Medicaid; providing financial assistance; and collaborating with community organizations, including faith-based organizations. For example, some IDSs operate FQHCs within their system, and others collaborate with local FQHCs that are not part of their system. In addition, to improve access to mental health care services for patients, including those in underserved populations, some IDSs integrate mental health and primary care services. IDSs in the sample reported facing various operational challenges in providing care, including care for underserved populations. Some reported that not receiving reimbursement from health care insurance companies for the care coordination services they provide to patients is a financial challenge. Other operational challenges IDSs identified included finding specialty care for underserved patients, including mental health care; sharing clinical information in patients' EHRs with providers outside the system; and changing management and physician cultures to adapt to organizational change. The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.