Financial Flows

We reviewed the scientific and grey literature between 2004-2014 through a search in Medline, EMBASE, The Cochrane Library of Systematic Reviews, EconLIT and CINAHL as well as websites of major health and social care government organisations, academic institutions, NGOs and think-tanks. The financial flows in the four Project INTEGRATE case studies on integrated care models in Germany, Sweden, Spain and The Netherlands were analysed. We also carried out a small survey including health care managers and researchers in the project INTEGRATE study countries, with data collected from Belgium, Estonia, Norway, Spain and Switzerland. We will review the scientific and grey literature on the topic and carry out a survey including health care managers and researchers in the project INTEGRATE study countries. The financial flows in the four Project INTEGRATE case studies will be analysed.

Fragmented financial systems, i.e. with separate funding streams and governance structures for different types of services, or provider payment mechanisms that do not adequately reward and encourage care coordination may create barriers to care integration. Payment mechanisms to independent providers rewarding volume provide little incentive for providers to collaborate and hamper service redesign. Separate budgets may create incentives to shift patients and costs to another level/part of the care system. Without agreed care pathways and accountability lines it may be difficult to realign incentives even across providers within a single payer system.

Payment reform options span from amending existing independent provider payment systems paying for coordination activities, e.g. on a ‘per member per month/year’ basis, mechanisms for payment across providers such as bundled payments along disease or entire care pathways, to population-based payments where providers assume responsibility for the health of defined populations. There are increased ambitions to move towards payment approaches that reward value instead of volume, and consider final health outcomes and patient satisfaction as well as costs.

Our literature review showed that the scientific evidence base for the specific impact of payment mechanisms and resource integration mechanisms on care integration are weak. A reason for this may be that a number of financial arrangements to support care integration have been introduced in recent years and are still at early stages of implementation. Furthermore, payment reform in healthcare is often challenging to evaluate as the effects of financial arrangements may be difficult to separate from other elements of service reorganisation.

Integrated payment mechanisms such as creating one price for the care package, can facilitate care integration. However, experiences with bundled payments show that high incidence of multi-morbidity in patients with chronic illness challenges disease-based payments, and that linking payment too closely to care standards may introduce too much standardisation, thus give too little room for adaptation to individual patient needs. Successful integrated care arrangements covering both health and social care can be achieved without full integration of financial flows if necessary structures to sustain and institutionalise the collaborative arrangements are in place. Providing financial support or start-up funding may help to reduce the risk of and hence ease the implementation of new integrated or coordinated service provision models.

Our research can add to the understanding of how to design, develop and introduce financial arrangements to support integrated care.