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Why the future of health care lies in integration 

First published in The Straits Times on 08 April 2013
What ails health care in Singapore ? In recent weeks, MPs and commentators have called for Medisave use to be liberalised, and suggested that regulators spell out core requirements of coverage that insurers must provide. The solution to the health-care crunch may not be building more hospitals, but better-integrated care.

A middle-aged diabetic woman experiences a gnawing tummy ache and sees her regular General Practitioner (GP). He prescribes antacids and warns her to watch for worsening pain.

Hours later, her condition worsens, and she is hospitalised. Delirious with pain, she cannot relate her medical history to hospital doctors or provide details of her earlier visit to the GP. A gamut of tests - some of which were already run by her GP - are carried out. It turns out she has appendicitis, and she undergoes surgery.

Upon her discharge, the hospital starts her on a totally different set of medication. All this time, her GP is unaware of what has happened to his patient, and both are confused when she turns up months later with bags of new drugs.

In my years as a practising doctor, I have seen too many of such cases. It may seem bewildering how the treatment of a patient can still often wind up inefficient, frustrating and very expensive despite rapid advances in medical science.

When it comes to responding to healthcare challenges such as ageing populations and spiralling costs, the kneejerk reaction of many governments has been to invest in infrastructure.

However, building more or bigger hospitals is not the solution for all healthcare challenges. Rather, the answer may well lie in addressing the current fragmented state of health systems.

Such fragmentation results in poor coordination among different care providers and an over-reliance on costly specialist care. It can also sometimes lead to unnecessary and duplicative tests which put patients through emotional and financial strain, and delays in timely diagnosis and treatment.

Why integration is key to healthcare’s future

The definition of integration varies among systems but at its heart, the idea is to be able to offer coordinated care across the whole patient journey.

Integration can be driven by payers such as insurers and governments, or be provider-led. An example of the former is De Friesland Zorgverzekeraar. The Dutch insurer coordinated health care providers within a region to shape networks of care. One network may include a range of services ranging from emergency and intensive care, to oncology and chronic care.

Exemplifying provider-led integration are the hospital systems in the United States (US). Many have integrated through merging primary and ambulatory care capabilities, home health and skilled nursing facilities, rehabilitation and other capabilities into one delivery chain.

These industry players are investing in integration because they believe that benefits can be reaped. Indeed, a growing body of evidence suggests that the quality of healthcare can be improved and costs lowered if healthcare provision is well-integrated.

One successful model of integration can be found in Coxa Hospital in Finland. The hospital, which specialises in joint replacement surgery, developed a partnership with primary care physicians and integrated the entire patient experience from referral, through initial visit and pre-operation, to operation, rehabilitation and follow up consultations. The result: 90 percent of its patients receive rehabilitative care in primary care closer to the home.

Besides excellent surgical outcomes and very low complication rates, Coxa received the highest national rankings in Finland for patient and staff satisfaction. Such positive outcomes are possible because of better coordination among healthcare providers, which allows for earlier detection and better treatment options. In other words, patients receive the right care at the right place and time, and by the right provider.

What is hindering the implementation of integrated health systems

Despite the growing number of success stories, most healthcare systems around the world are still struggling with integration.

For one, technical aspects such as developing registries and sharing records digitally can be challenging for less mature systems. Even more difficult are establishing accountability for outcomes and developing financing models to determine how payment is reimbursed to different providers.

The human element is another major challenge. Health professionals with differing approaches and risk appetites must overcome a history of working in silos while patients’ beliefs and attitudes have to change.

In an integrated health network, doctors at the GP or community level may be identified as the ones who should provide appropriate care. Patients must therefore understand that the most advanced and expensive treatment in the newest hospital may not be the best or even necessary. This is especially so in the early or more stable phases of chronic disease. In fact, hospital stays can be costly and expose patients to the unnecessary risk of hospital acquired infections.

The road forward for Singapore

In Singapore’s recent Budget announcement, the Ministry of Health announced plans to build six new public general hospitals, and 12 to 14 additional polyclinics by 2030. These are on top of previously announced plans to triple community hospital beds and double long-term care capacity by 2020.

It is vital to ensure that these new institutions in Singapore operate within the context of integrating services within our Regional Health Systems (RHS). In place since 2009, RHSs such as the Eastern Health Alliance and the Alexandra Health System have been actively joining the dots in their respective regions. They are forming partnerships among GPs, community hospitals, nursing homes and other stakeholders to care for their patients within respective designated zones.

The path to integration will not be easy given how there has always been a divide between public and private sectors; GPs and specialists; and hospitals and community-based care in Singapore.

It might be useful at the national level to consider how we can facilitate stronger partnerships among healthcare providers. Provision of additional funding and other incentives to successfully integrated parties, and better defining the new partnerships in care are all strategies which can be looked into.

With ageing and chronic diseases looming on our shore, the end-goal of a coordinated and sustainable healthcare system is worth every effort.

This article is contributed by Dr Loke Wai Chiong, Director, Global Healthcare Practice, KPMG in Singapore. The views expressed are his own.