Health Care Delivery: Features of Integrated Systems Support Patient Care Strategies and Access to Care, but Systems Face Challenges
Published: 2010-11-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: Health care delivery in the United States has long been characterized by  fragmentation at the national, state, and local levels. Care is delivered by  multiple providers, in multiple care settings, and often without systematic  coordination and communication across providers and settings.  Fragmentation of care delivery can lead to poor quality of care, medical  errors, inefficient delivery of services, higher costs, and patient  dissatisfaction. Fragmentation can be especially burdensome for patients  with chronic illnesses because of their ongoing care needs and for  underserved populations—individuals who are uninsured or medically  underserved—because of their financial and other challenges to accessing  services.
One way that hospitals, physicians, and other providers have addressed  fragmentation is by forming integrated delivery systems (IDS) to improve  efficiency, quality, and access to care. An IDS can be integrated across its  providers and facilities in terms of such aspects as clinical care, financial  management, and human resources. These systems can vary in the way  they are organized, with services linked vertically, among different levels  of care (e.g., clinic, specialist’s office, hospital), or horizontally, across one  level of care (e.g., hospitals). They can also vary in the extent to which  they are integrated. IDSs can be publicly owned or private. While public  IDSs have a mission of providing care to underserved populations, some  private IDSs share this mission and others serve these populations to  varying degrees.
The Health Care Safety Net Act of 2008 directed GAO to report on  integrated health system models that integrate primary, specialty, and  acute care and serve uninsured and medically underserved populations.  We provided an oral briefing to congressional staff on October 8, 2009. In  this follow-on report, we provide more in-depth information on  1.  organizational features that IDSs use to support strategies to improve  2.  approaches IDSs use to facilitate access to care for underserved  3.  challenges IDSs encounter in providing care, including care provided  to underserved populations.
subsections: section_title: Scope and Methodology
paragraphs: To address our research objectives, we selected a judgmental sample of   15 IDSs that clinically integrate primary, specialty, and acute care and  serve uninsured and medically underserved populations. To select our  sample, we began by reviewing published research and interviewing  researchers with expertise in IDSs. As a result, we identified 44 public and  private nonprofit systems from which to select our sample. In December  2009, we sent a Web-based data collection instrument to these systems to  determine the extent of their clinical integration and to obtain additional  information about organizational features of the system. This included  whether the system is made up of subsystems—local or regional delivery  systems that are organized below the system level—that integrate clinical  care within themselves. We sent e-mail reminders and conducted  telephone outreach to systems that had not responded by our requested  deadline. In the end, we received completed data collection instruments  from 19 systems. We excluded 4 systems from our study because their  responses indicated a lack of clinical integration or because of an  affiliation with a “closed system”—one that exclusively serves members of  the system’s health insurance plan. Our final sample consisted of 15 IDSs,  which include five subsystems. (See table 1.)
The 15 IDSs vary in many aspects, including the degree to which they are  integrated, specific organizational features, and payer mix (e.g., extent to  which they serve Medicare and Medicaid beneficiaries and the uninsured)  (see app. I). We reviewed the Web sites for the IDSs in our sample,  relevant articles and reports about the systems, and other documents the  systems provided. Based on our review of the extent of clinical integration  of each system, its location (census region and urban/rural), and whether  it is publicly or privately owned, we selected for site visits four systems  that reflected variation among these dimensions: Ascension Health’s Seton  Family of Hospitals, Denver Health, Henry Ford Health System’s Detroit  Region, and New York City Health and Hospitals Corporation’s (NYCHHC)  Queens Health Network. We administered a structured interview protocol  with chief medical officers (or other system officials, as appropriate) to  obtain information on organizational features that IDSs use to support  strategies to improve patient care; approaches IDSs use to facilitate access  to care for underserved populations; and challenges IDSs encounter in  providing care, including care provided to underserved populations. To  gain additional in-depth information, we conducted interviews with IDS  officials at the four sites we visited, including system executives and  clinical staff. In some cases, information provided by IDS chief medical  officers and officials is specific to underserved populations, and we note it  as such in this report. In other cases, the information is more general,  relating to the overall system or patient population, which can include  underserved patients.
Findings in this report are based on a judgmental sample and are not  generalizable to all IDSs. The organizational features, patient care  strategies, approaches to facilitate access, and challenges that we describe  are not necessarily unique to IDSs, but may also be found in other health  care settings and experienced by different providers. However, the  information we present is from the perspective of the IDSs in our sample.  We relied on data obtained through the Web-based data collection  instrument, interviews with system representatives, and published studies  and did not conduct independent analyses of the effectiveness of  strategies.
We conducted this performance audit from June 2009 to November 2010,  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Background
paragraphs: IDSs vary in their organizational configuration and in the continuum of  services they provide. They frequently use patient care strategies such as  care coordination, disease management, and care protocols. Other  providers that are not part of IDSs may also use some of these strategies  and may also face challenges similar to those IDSs may face. For example,  some IDSs serve a patient population that includes a high proportion of  underserved individuals and may face financial challenges in doing so.  Other providers who also serve a high proportion of underserved  individuals may face some of the same financial challenges.
subsections: section_title: Organization of IDSs
paragraphs: IDSs can be organized in different ways and use various staffing models.  Some IDSs are a single entity that includes a delivery system (hospitals,  physicians, and other providers) and a health insurance plan. Examples of  this type of IDS include NYCHHC and Geisinger Health System. Other IDSs  include a delivery system but do not have a health insurance plan, such as  Partners Healthcare and Memorial Healthcare System. IDSs may employ  their own physicians, rely on community-based physicians who are not  employed by the system but are granted use of the hospital facilities and  staff, or use a combination of those two approaches. An IDS can be  organized at the system level, or it can be more decentralized, having  subsystems that organize health care at the local or regional level. These  subsystems integrate care within themselves but not necessarily with  other subsystems in the overall system. IDSs can consist of multiple  subsystems. Because there is so much variation in the ways that IDSs can  be organized, it is difficult to determine the exact number of IDSs in the  country; however, millions of Americans receive care from IDSs.
IDSs offer a continuum of services to a particular patient population or  community and can vary in what services are provided within this  continuum. For example, some IDSs provide nursing home care within  their systems, and others do not. Similarly, not all IDSs provide certain  specialized services such as organ transplantation or major burn services  within their systems. An IDS may have a contract with other providers to  offer certain services, or may refer patients to providers not affiliated with  the IDS for a service.
section_title: Patient Care Strategies Used by IDSs
paragraphs: IDSs use multiple strategies to improve patient care, such as care  coordination, disease management, clinical practice guidelines, and care  protocols. Care coordination is the integration of patient care activities  between two or more participants involved in a patient’s care to facilitate  the appropriate delivery of services. It occurs across the continuum of  care and across different delivery sites, encompassing both health care  and social support interventions, and is often used for patients with  special health care needs or chronic health conditions. Care coordination  activities can include case management and patient navigation services.  Disease management involves providing coordinated health care  interventions and communications to patients who have chronic  conditions, such as diabetes or asthma, where patients’ self-care efforts  can affect their health outcomes. Disease management is a systematic  approach to patient care that uses evidence-based practice guidelines.  Evidence-based practice guidelines, also referred to as clinical practice  guidelines, are systematically developed statements that guide providers  and patients in making decisions about appropriate health care for certain  conditions. They are typically based on an examination of the best  available scientific evidence and broad consensus about the best  treatment to follow. Care protocols, which are generally more specific  than guidelines, provide more detail about the management and treatment  of diseases and conditions. Patient care strategies can be designed to  achieve a variety of goals, such as improved health outcomes and quality  of care, increased efficiency, and lower costs. They may be performed by  physicians, nurses, or other clinical or nonclinical staff members and often  are implemented outside of a patient’s face-to-face appointment with a  physician.
Studies have shown that IDSs are more likely to use patient care strategies  than are other providers, such as solo practitioners. For example, a  national study of the management of chronic illness for patients with  asthma, congestive heart failure, depression, and diabetes found that  certain IDSs were significantly more likely to use recommended, evidence- based care management processes than were less organized providers. In  addition, a study of physician practices in California in the early 2000s  found that physicians affiliated with an IDS were more likely to use  disease management programs than were physicians in nonintegrated  medical group practices or small practices.
section_title: IDSs’ Role in Serving Underserved Populations
paragraphs: Depending on their geographic location and their mission, IDSs serve  varying proportions of underserved populations. Individuals who are  underserved have higher rates of illness, and they often face barriers to  accessing timely and needed care. For example, uninsured patients are  more likely than insured patients to have chronic illnesses that are  undiagnosed or undertreated. People with limited English proficiency  may have problems comprehending health care information and  complying with treatment. Rural residents also face barriers to access  because of physician shortages in rural areas. In addition, underserved  patients may have difficulty obtaining specialty services, including  diagnostic services. Integrating care, such as by linking primary and  specialty care, can reduce some of the access barriers that underserved  populations experience.
section_title: IDSs Reported That Using Electronic Health Records, Operating Health Insurance Plans, and Employing Physicians Support Strategies to Improve Patient Care
paragraphs: The 15 IDSs in our sample collectively reported that organizational  features such as using electronic health records (EHR), operating health  insurance plans, and employing physicians all support various strategies  for improving patient care, including care coordination, disease  management, and use of care protocols.
subsections: section_title: Using EHRs Was Reported to Support Patient Care Strategies by Increasing Availability of Patient Information
paragraphs: Officials at some IDSs in our sample told us that using EHRs supports  their strategies to improve the quality of patient care by increasing the  availability of clinical information and patient population data and by  improving communication. All 15 IDSs reported having implemented EHRs  to some extent. For example, as of March 2010, Seton was in the process  of implementing its EHR, and Henry Ford’s EHR was available at all of its  facilities. Clinical strategies supported by using EHRs include care  coordination, disease management, electronic prescribing (e-prescribing)  and computerized physician order entry (CPOE), and care protocols.
subsections: section_title: Care Coordination
paragraphs: According to officials at some IDSs, using EHRs facilitates care  coordination because EHRs make patient clinical information more  readily available to providers and improve communication among  providers, staff, and patients. For example, officials from Denver Health  characterized the EHR as a key component of integration. At Denver  Health, the EHR supports care coordination because physician notes from  patient encounters are scanned in within 24 hours of patient contact and  clinical information, such as previous laboratory tests, is available to all  providers (for additional information, see sidebar). Similarly, an official  from Mayo Clinic told us that the EHR helps avoid overutilization and  duplication of services, and an official from Partners Healthcare told us  that the EHR aids in care coordination because physicians can see patient  clinical information no matter where in the system the patient is.  Marshfield Clinic’s EHR is also available at all of its facilities, giving  providers access to clinical information, digital radiology images, and  capabilities such as e-prescribing. At Marshfield Clinic, each patient’s EHR  contains a “dashboard” with information on preventive services to  highlight needed services and to facilitate communication among  providers so that services and assistance can be requested electronically.  Marshfield’s EHR also creates a list of high-risk patients with outcomes in  need of interventions so that physicians and other staff can follow up with  those patients.
section_title: Disease Management
paragraphs: According to IDS officials, using EHRs facilitates disease management by  making patient-level and population-level data available to providers,  which allows providers and IDSs to adjust approaches to treatment based  on individual patient and population-wide progress. NYCHHC, for  example, has disease management programs for patients with asthma,  diabetes, congestive heart failure, hypertension, cardiovascular disease,  and depression. Each regional subsystem within NYCHHC has its own  separate EHR. The EHRs update disease registries nightly, and through the  disease registries, providers can develop a comprehensive understanding  of a patient over time. For example, providers can assess a given diabetic  patient’s health status at any point in time, and compare it to another point  in time to ascertain what may have been associated with a change in  health status. The diabetic disease registry also enables NYCHHC  physicians with similar groups of patients to compare their patients’  outcomes. NYCHHC officials said that information technology makes it  easier to get data and identify trends, and that EHRs allow them to  anticipate and mitigate potential problems more easily and much earlier.  Because the EHR provides real-time clinical information, providers are  able to see test results immediately upon completion, which might not be  possible without an EHR. Having real-time information allows providers to  initiate appropriate treatment or follow-up. Similarly, the Doc Site Registry  at Henry Ford, which uses a common EHR across all its facilities, is a  disease registry program available for all patients that is linked to the  EHR. It covers diseases such as depression, chronic obstructive  pulmonary disease, hypertension, asthma, and chronic kidney disease. The  Doc Site Registry prompts providers to administer missing preventive  services during patients’ visits. Staff at Henry Ford use the Doc Site  Registry to identify groups of patients who are in need of care  management. In addition, Hennepin Healthcare System has used an EHR  system since February 2007 for both inpatient and outpatient services.  According to officials at Hennepin Healthcare System, the EHR is  fundamental to providing real-time awareness and support for providing  clinical care, including care for patients with chronic diseases. One of the  officials added that using data from the EHR enables them to determine  which interventions are more effective in specific circumstances and gives  the staff insight into how to improve care.
Officials at some of the IDSs reported that using EHRs with e-prescribing  and CPOE capabilities reduces errors and lowers costs. For example,   e-prescribing at Marshfield Clinic was reported to reduce errors related to  illegible handwriting and unintentional drug interactions. Through the  EHR, prescribers are alerted when an allergy or drug interaction exists.  Marshfield Clinic’s EHR also requires physicians to consider appropriate  alternatives for prescription drugs, and a study found that Marshfield  Clinic’s suggestions of “preferred alternative” prescription drugs saved  payers and patients $2.5 million in 1 year. In addition, NYCHHC officials  told us that its CPOE includes drug interaction warnings and improves the  legibility of physician orders.
section_title: Care Protocols and Clinical Practice Guidelines
paragraphs: Officials from some IDSs told us that their systems’ EHRs facilitate the use  of care protocols and clinical practice guidelines by prompting providers  to use them and tracking their use. At Denver Health, for example, when  entering an order into the CPOE through the EHR, the physician is  presented with a standard set of orders that is applicable to the patient.  The sets of orders are linked with guidelines explaining the need for the  specific orders, and physicians must explicitly de-select any orders they  disagree with. A Denver Health official told us that guidelines incorporated  into the EHR’s CPOE function are more likely to be followed than  standalone guidelines. One example of the use of standardized order sets  is for Denver Health patients with ketoacidosis; this use of standardized  order sets was associated with a 23 percent decrease in intensive care unit  length of stay and a 30 percent decrease in hospital length of stay. In  another example, Allina Hospitals & Clinics, which uses a single EHR  system at all 11 of its hospitals and for all of its employed physicians,  created systemwide pneumonia vaccine guidelines to better identify  patients eligible for the vaccine. Allina Hospitals & Clinics’ EHR  electronically prompts the nurse to use the guidelines at the time the  patient is assessed for admission.
section_title: Operating a Health Insurance Plan Was Reported to Support Patient Care Strategies by Providing Resources and Increasing the Availability of Data on Patients in the Plan
paragraphs: Officials from IDSs in our sample reported that operating a health  insurance plan can support patient care strategies by providing to the IDS  both financial resources, such as savings resulting from reducing  avoidable hospitalizations for health plan members, and data on health  insurance plan members. IDS officials reported that financial resources  could be used to fund services such as care coordination—which many  insurers do not reimburse—and the data could be used as a basis for  implementing strategies such as disease management.
subsections: section_title: Care Coordination
paragraphs: A Geisinger Health System official discussed how operating a health  insurance plan could enable an IDS to invest financial resources in  coordinating care for patients insured by the plan. The official said one  way that the Geisinger Health Plan provides care coordination is through  its ProvenHealth Navigator program. Geisinger Health Plan hires nurses  trained in population health management to work in primary care settings,  where they provide specialized care coordination and preventive services  for the plan’s high-risk patients. According to the Geisinger Health System  official, the ProvenHealth Navigator program is associated with reductions  of up to 30 percent in hospital readmissions and about 20 percent in acute  admissions. Because Geisinger Health System hospitals have fewer  admissions, Geisinger Health System revenues from hospital care are  reduced. However, for the overall system, the reduced revenue has been  offset by savings the health insurance plan experiences because it is  paying for fewer hospital admissions for its members. Furthermore,  patients have benefited from avoiding preventable hospital stays.
section_title: Disease Management
paragraphs: Officials at some IDSs provided us with examples of ways that operating a  health insurance plan enables them to allocate resources for disease  management services or enables them to create better-informed disease  management programs by providing access to useful patient information  through the tracking of health insurance plan data. Henry Ford  implemented an innovative protocol for use of an outpatient heparin  treatment in place of an inpatient heparin treatment for patients with deep  vein thrombosis before outpatient heparin was the standard of care. The  type of heparin used in the outpatient treatment was not covered by most  insurers. Because Henry Ford controls its own insurance benefit through  its health insurance plan, the Health Alliance Plan, it was able to cover the  cost of the outpatient heparin, which was associated with a decreased  length of stay, as well as a decreased cost per admission. Henry Ford also  uses its health insurance plan claims data to better inform patient care.  For example, Henry Ford has access to over 10 years of data on patients  with osteoporosis, allowing it to know how patients were treated and  what the outcomes of those treatments were, which can guide future  efforts to manage treatment of osteoporosis. Similarly, an official from  Intermountain Healthcare told us that it used its health insurance plan  data to identify patients with conditions such as hypertension and diabetes  and conduct targeted education for those patients through mailings and  other initiatives.
section_title: Some IDSs Reported That Employing Physicians Supports Patient Care Strategies by Ensuring Physician Participation in Quality Efforts
paragraphs: Employing physicians, rather than relying solely on community-based  physicians who are not employed by the system, may facilitate strategies  to improve the quality of patient care at an IDS, in part because of the  IDS’s ability to require or encourage certain aspects of care and to monitor  certain aspects of the care employed physicians provide. At each of the 15  IDSs in our sample, some physicians are employed by the IDS. Strategies  supported by the employment of physicians include accountability for  quality of care, use of care protocols, and mitigation of physician concerns  related to payment for care for underserved populations.
subsections: section_title: Accountability for Quality of Care
paragraphs: Employment of physicians was reported to facilitate physician  accountability for quality of care because physicians who are employed by  the IDS are expected to meet certain performance indicators, and the IDSs  collect data on and review physician performance. For example, an official  from Memorial Healthcare System said that employed physicians are  expected to comply with performance indicators, but that Memorial  Healthcare System does not have the same leverage with community- based physicians it does not employ as it has with the physicians it  employs. The Memorial Healthcare System official told us the system can  compare an employed physician’s data with those of its other employed  physicians and with performance benchmarks, and that such data  comparisons help motivate physicians to improve their performance. A  Denver Health official told us that the employment of physicians is an  important part of implementing physician accountability and quality of  care, and that physicians that the system employs are more likely to fully  support hospital initiatives than are community-based physicians who are  not employed by the system. An official from Intermountain Healthcare  said that physicians are motivated to improve performance when  presented with a comparison of individual performance indicators and  peer performance indicators, and Intermountain Healthcare is able to  provide more detailed information on physicians it employs because of the  employed physicians’ use of the EHR.
section_title: Use of Care Protocols
paragraphs: Officials from some IDSs told us that employment of physicians can  increase adherence to care protocols, because IDSs can require or  encourage their use. For example, Geisinger has a pay-for-performance  program for providers of coronary artery bypass graft surgery for  Geisinger patients. Because Geisinger employs these surgeons, it can  require them to follow 40 care protocols through its ProvenCare Heart  Program. In a 2007 study, adverse outcomes occurred less often in the  ProvenCare treatment group than the control group, the latter of which  consisted of patients treated before the implementation of ProvenCare,  and the likelihood of the patients being discharged to their home rather  than to another care facility was higher. In addition, an official from  Memorial Healthcare System told us that employed physicians are  expected to follow protocols for chronic conditions. Memorial Healthcare  System can track whether employed physicians—in both inpatient and  outpatient settings—are using the protocols, and employed physicians  receive feedback on their compliance with protocols. Memorial Healthcare  System can track use of protocols for other physicians who provide  inpatient services, but cannot track use of the protocols for other  physicians who provide outpatient services.
section_title: Mitigation of Physician Concerns Related to Payment
paragraphs: Officials from several IDSs told us that employment of physicians can  facilitate provision of care to underserved populations because  compensation from IDSs can mitigate physicians’ concerns that they may  not receive payment from uninsured patients. For example, an official  from Intermountain Healthcare told us that physicians receive the same  compensation regardless of the patient’s insurance status. At Henry Ford  Hospital, where the Henry Ford Medical Group is the sole source of  physician staffing, the physicians are expected to provide the same  standard care processes, which are evidence-based, without considering  the patient’s insurance status, and often physicians do not know what the  patient’s insurance status is. Similarly, the Sisters of Mercy Health  System’s St. Edward Mercy Health System has a set compensation  structure for newly hired primary care physicians for at least 2 years under  which there is no financial incentive for them to distinguish among  patients of different insurance status. After 2 years, primary care  physicians are asked to take at least 10 percent of their patients from  Medicare or Medicaid populations, and they are reimbursed at a rate  similar to that of commercial insurance for patients from those  populations that exceed the 10 percent level (up to 20 percent).
section_title: IDSs Use Community- Based Settings and Other Approaches to Facilitate Access to Care for Underserved Populations
paragraphs: The IDSs in our sample discussed several approaches that they use to  facilitate access to care for underserved populations. These include  providing community-based care, conducting outreach, helping patients  apply for coverage programs, providing financial assistance, integrating  mental health and primary care services, and collaborating with  community organizations.
subsections: section_title: Providing Community-Based Care
paragraphs: Officials from some IDSs reported providing underserved children with  some of the health care services along their continuum of care—such as  primary care, mental health care and counseling, and health education— through school-based health centers (SBHC). Examples of IDSs with  school-based health centers serving underserved children include Denver  Health, Henry Ford, Intermountain, NYCHHC, and Parkland Health &  Hospital System. Henry Ford’s SBHCs provide management of chronic  illnesses, such as asthma and diabetes, and mental health counseling and  referral in addition to their primary care services. Intermountain’s SBHCs  have expanded access to their health services to family members of the  children they serve.
Federally Qualified Health Centers (FQHC)
Officials from several IDSs reported either operating or collaborating with  FQHCs to provide care to underserved populations. Some IDSs, such as  Denver Health and Parkland, operate FQHCs within their systems. All of  Denver Health’s 12 school-based health centers are FQHCs, as are all 8 of  its primary care clinics, its urgent care center, and its hospital-based  women’s care clinic. Similarly, Parkland’s Homeless Outreach Medical  Services, which operates mobile health units in partnership with the City  of Dallas, is an FQHC. At two other IDSs—Seton and Henry Ford—there  are no FQHCs among the clinics in their system, but both IDSs collaborate  with local FQHCs that are not part of their system. For example, Henry  Ford collaborates with two local FQHCs, facilitating access to primary and  specialty health care services. The FQHCs provide primary care services  to patients, and Henry Ford provides needed specialty care services. In  addition, Henry Ford collaborates more broadly with one of the FQHCs,  providing resources to help meet the clinic’s needs (for additional  information, see sidebar). Another IDS, Marshfield Clinic, has a  contractual partnership with an outside FQHC through which Marshfield  Clinic provides primary and preventive health care and dental care to low- income uninsured and underinsured individuals and families. Marshfield  Clinic also supported the establishment of the FQHC by helping it apply  for federal grant funding.
Some IDSs operate mobile health units to expand access to care for  underserved populations, such as people who are homeless and residents  of rural areas. For example, Parkland’s Homeless Outreach Medical  Services mobile health units visit Dallas area homeless shelters to provide  medical and social work services to children and adults. Services include  immunizations, care for acute and chronic conditions, health education,  and well-child care. To facilitate access to health care services for patients  in rural communities, especially those who are uninsured, Seton operates  a mobile mammography program and a mobile pediatric clinic. The mobile  mammography program provides free mammography screening, breast  self-examination instruction, and a clinical breast examination as well as  eligibility screening for available public and Seton-sponsored health  coverage. A nurse provides case management services for women  screened through the mobile mammography program. The mobile  pediatric clinic serves children through age 21, providing services such as  well-child care, immunizations, and chronic disease management.
Some IDSs, such as Marshfield Clinic, St. Edward Mercy Health System,  and Geisinger, facilitate access to certain health care services to patients  in rural areas by using telehealth to provide services such as primary care,  mental health care, and certain specialty services. Telehealth enables  providers to interact remotely with patients and other providers by using  electronic communication and technologies such as video conferencing,  bringing a wider range of services to underserved individuals in their  communities. For example, Marshfield Clinic telehealth services are  available in 40 medical specialties at 55 sites, including dental clinics,  skilled nursing facilities, Head Start clinics, a rural hospital, and 31 rural  clinics, 5 of which are FQHCs. Telehealth is available in care areas such as  mental health, dentistry, and primary care. Through telehealth, Marshfield  Clinic specialists and primary care providers consult with each other and  outside referring physicians, and Marshfield Clinic patients can receive  services from other specialists located in academic medical and research  centers throughout the country. St. Edward Mercy Health System  facilitates access to health care services for pregnant women and  newborns in rural communities through its participation in the perinatal  telehealth program of the University of Arkansas for Medical Sciences and  Arkansas Children’s Hospital. The program links physicians at St. Edward  Mercy Medical Center with a neonatalogist or an obstetrician who  specializes in high-risk pregnancies for consultation. To facilitate access to  psychiatric services for veterans living in rural communities, Geisinger  incorporates telemedicine into its Reaching Rural Veterans program. The  program uses telehealth and a patient navigator to identify and assist  veterans who have post-traumatic stress disorder and their families and  connect them to local private and public resources.
section_title: Conducting Outreach
paragraphs: Most IDSs in our sample conduct outreach targeted at underserved  populations. IDSs engage in outreach activities such as health education,  health screening, and linking individuals with providers for needed health  care services. For example, Denver Health conducts outreach to  underserved men in targeted neighborhoods and at the Denver County jail  through its Men’s Health Initiative. The Men’s Health Initiative provides  basic health screening; case management services, including services for  men with complex health care needs; and referrals for specialty health  care services. At Cambridge Health Alliance, volunteer health advisors  work in the community to conduct health education and screening,  participate in health fairs, provide referrals for services, and lead  culturally and linguistically appropriate peer support groups such as those  for patients with chronic conditions. According to Cambridge Health  Alliance, since 2001 the volunteer health advisor program has provided  8,100 screenings, and more than 700 individuals have been enrolled in  health coverage and referred to a primary care doctor.
section_title: Helping Patients Apply for Coverage Programs
paragraphs: All IDSs in our sample facilitate access to care for uninsured patients by  helping them complete applications for public coverage such as Medicaid  and local coverage programs. At some IDSs, application assistance is a  component of community outreach activities, such as in Denver Health’s  Men’s Health Initiative. Two systems—Seton and Parkland—use a Web- based tool to screen for eligibility for federal, state, and local health  insurance programs. According to Seton representatives, using the Web- based tool enables the system to adopt a “no wrong door” approach,  screening patients for eligibility regardless of where the patient enters the  system. With the Web-based tool, Seton can track whether patients  submitted applications, remind patients to do so, and track their  enrollment status. Parkland uses the tool, which screens for eligibility for  about 100 programs, at its main campus and all of its community health  clinics, school-based health centers, and other locations.
section_title: Providing Financial Assistance
paragraphs: Many IDSs in our sample also provide financial assistance, such as a  sliding fee scale, for health care services to patients who are uninsured  and do not qualify for public health insurance programs. For example,  NYCHHC operates the HHC Options program, through which individuals  who are uninsured or underinsured and meet income requirements pay a  fee based on income and family size for health care services. Officials from  another IDS, Seton, told us that it operates a “health insurance-like”  program known as Seton Care Plus, through which uninsured individuals  who meet income requirements can access health care services. Seton  Care Plus enrollees pay a fee based on income for primary care services  provided at Seton primary care clinics and receive discounts for specialty  services from community specialists who have agreed to provide such  services. According to officials from Seton, although Seton Care Plus is  not insurance, it is similar in some ways, such as in its requirement for  prior authorization for certain services and in its tracking and monitoring  of the use of medical services. (For additional information on HHC  Options and Seton Care Plus, see sidebar.)
section_title: Integrating Mental Health and Primary Care Services
paragraphs: To improve access to mental health care services for patients, including  for underserved populations, some IDSs integrate mental health and  primary care services by providing mental health screenings in primary  care locations or collocating mental health providers in primary care  settings. For example, the NYCHHC Queens Health Network, which serves  a high proportion of patients who are uninsured or have Medicaid  coverage, annually screens all adult patients with diabetes for depression  in primary care settings. The primary care physicians treat patients with  mild to moderately severe depression, and patients needing more  specialized care are referred to the mental health clinic. Similarly, Henry  Ford conducts depression screening for patients with chronic conditions.  Henry Ford implemented a two-step screening process—which is  embedded in the EHR—in its primary care clinics. The patient is first  screened using a two-item screening questionnaire, and if that screening  indicates a need, the patient completes a second, more extensive  depression screening. The EHR uses the patient’s responses to notify the  primary care provider if treatment for depression is required and provides  the evidence-based treatment protocol. Henry Ford reported that in a   12-month period from June 2007 to June 2008, its primary care doctors  were providing treatment for depression to 67 percent of the patients they  identified through screening. In addition, two IDSs with facilities in  Minnesota, Mayo Clinic and Allina, participate in a collaborative care  model in which primary care providers screen and treat adult patients with  depression. Primary care providers use a standardized questionnaire to  assess symptoms of depression, a tracking system to monitor patient  status, a medical guide for identifying appropriate treatment, care  coordination for patients, a psychiatrist who is available for consultations,  and tools for preventing relapses by patients in clinical remission.
Another way some IDSs facilitate access to mental health care services is  by collocating providers such as social workers, nurses, and psychiatrists  in primary care settings. For example, Denver Health collocates some  mental health providers in community health clinics and school-based  health centers. Some of the community health clinics have a limited  number of mental health providers on site, as well as a psychologist or  psychiatrist. Staff at the school-based health centers include master’s level  mental health clinicians and child psychiatrists for consultations as  needed. Another example of an IDS that collocates primary care and  mental health care is NYCHHC, where most mental health clinics are  collocated with primary care clinic locations. Therefore, patients needing  both primary care and mental health services can obtain those services in  one location.
IDS officials told us that improving access to mental health care could  have a beneficial effect on a patient’s physical health. A Denver Health  official noted that patients with unmet mental health care needs could face  difficulty adhering to medical care treatment plans. Similarly, a staff  member at Seton’s community clinic commented that diabetic patients  who are depressed and therefore not taking care of themselves often  cannot manage the disease appropriately.
section_title: Collaborating with Community Organizations
paragraphs: Officials from most of the IDSs in our sample reported collaborating with  community organizations to facilitate access to care for underserved  populations. In these collaborative efforts, IDSs work with organizations  such as other providers and faith-based organizations, sometimes  providing financial resources or directly providing patient care, referrals,  screening services, or health education. For example, Seton collaborates  with other local organizations through the Health Alliance for Austin  Musicians (HAAM) to provide physical and mental health care services to  low-income, uninsured musicians in Austin, Texas. Seton provides primary  care services through Seton Care Plus to HAAM members, while other  community organizations offer mental health, dental, and audiology  services. Although HAAM members obtain mental health care services  through a HAAM mental health provider, they obtain medications  prescribed by that provider through Seton Care Plus, which gives them  access to low-cost prescription drugs. Hennepin Healthcare System  collaborates with other providers in its community on a pilot program to  help patients who sought nonemergency care in the emergency  department to find a primary care home.
Some other IDSs collaborate with health clinics in their communities by  providing in-kind and financial resources. For example, Intermountain and  Geisinger provide financial assistance to local health clinics. St. Edward  Mercy Health System provides office space to a local community  organization that provides social services and assistance to children who  have been abused, and a St. Edward Mercy Health System physician serves  as medical director for the organization. Some of the systems in our  sample work with local faith-based organizations. For example, Henry  Ford works with 15 to 20 local churches to offer health education and  screening related to issues such as nutrition, cancer, and heart disease.  Memorial Healthcare System and Parkland also collaborate with area  churches to conduct outreach, provide some health care services, or  provide health education and screening.
section_title: IDSs May Face Various Operational Challenges in Providing Care
paragraphs: IDSs in our 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 reported included finding  specialty care for underserved patients, including mental health care;  sharing information with providers outside the system; and changing  management and physician cultures to adapt to organizational change.
subsections: section_title: IDSs May Face the Financial Challenge of Not Receiving Reimbursement for the Care Coordination Services They Provide
paragraphs: Officials from some IDSs in our sample said that not receiving health  insurance reimbursement for the care coordination services they provide  is a financial challenge. While all the IDSs in our study provide these  services as a patient care strategy, such services are generally not covered  by health insurance. For example, Cambridge Health Alliance provides  patient navigation and care management services but does not receive  reimbursement for those services from health insurance companies.  Cambridge Health Alliance said that because these services are necessary  for treating certain patients, including those with mental illness, it  continued to provide the services without receiving payment for them.  Similarly, Henry Ford operates a pediatric medical home program that  includes care coordination services, but does not receive health insurance  reimbursement for these services. Allina cannot bill for services provided  by its nonclinical care guides, whose services are part of a broader care  coordination strategy. The care guides are trained to provide one-on-one  counseling and patient navigation services to patients diagnosed with a  chronic disease to help them meet their clinical goals. Allina told us that  the Care Guide program increased the number of clinical goals that were  met for participating patients and decreased inpatient care costs. An Allina  official also commented that because Allina provides these services  without receiving health insurance reimbursement and it does not operate  a health insurance plan, it cannot recoup the savings that may result from  care coordination, such as the reduced need for services for preventable  events.
section_title: IDSs May Face Difficulties in Finding Specialty Care, Including Mental Health Care, for Underserved Patients
paragraphs: Some IDS officials said that finding specialty care, including mental health  care, for their underserved patients has presented challenges. The  challenges that IDSs may face in finding mental health care providers  include recruiting and funding providers to practice in the system and  identifying providers in the community to accept referrals of underserved  patients. For example, an official from Marshfield Clinic, which serves a  rural population, told us the system has difficulty recruiting mental health  care providers for its patient population, including Medicare and Medicaid  beneficiaries. As a result, the mental health care providers at Marshfield  Clinic have a large patient caseload and find it difficult to spend time  collaborating with other types of providers to integrate care. Like  Marshfield, Seton experiences difficulty recruiting psychiatrists to practice  at one of its rural facilities. Seton officials also told us that while  previously a psychiatrist worked in one of the system’s urban primary care  clinics, the clinic could not sustain the funding for the position. Clinic staff  said they are able to consult with a psychiatrist only on a limited basis, and  that there are many patients at the clinic who have serious mental illnesses  but cannot access the care they need. In addition, Seton officials told us it  is challenging to find psychiatrists in the community to accept referrals for  the system’s Medicaid and uninsured patients.
Officials from some IDSs also told us that, in certain circumstances, they  face challenges when seeking other types of outside specialty care for  their underserved patients. For example, Sisters of Mercy refers patients  to practices outside its system for certain specialty care that is not  available within its system. However, it sometimes encounters problems  finding outside specialty providers to treat its uninsured patients. Seton  has also experienced this challenge. To fulfill its mission to provide health  care to underserved populations, Seton provides primary care services to  uninsured patients through its community clinics. It also participates in a  program through which it recruits specialists from the community who  agree to see a certain number of uninsured patients, but it has experienced  difficulty finding specialists to participate in this program and provide  specialty care to Seton patients.
section_title: Sharing Information in EHRs with Outside Providers May Present Challenges to IDSs
paragraphs: Some IDS officials described challenges related to sharing the clinical  information in patients’ EHRs with providers outside of their systems. To  improve availability of patient clinical information, some IDSs make their  EHRs available to outside providers that also treat their patients. Of those  IDSs, some reported that while the outside providers can read the EHRs,  they cannot directly enter clinical information. For example, Geisinger  makes its EHR available to outside providers to give them immediate  access to patient medical records, but the providers are not able to enter  any additional clinical information directly into the EHR. Geisinger can  scan this information into the EHR if the outside provider communicates  it, but scanning is not instantaneous, as direct entry would be. A Geisinger  official noted that while scanning is not optimal, absent a common EHR  where information can be directly entered, the scanned records can be a  helpful supplement to a patient’s EHR in many cases. Similarly, providers  serving patients at the FQHCs that Henry Ford partners with can only view  information in the EHR and cannot directly enter clinical information  themselves. While the Geisinger and Henry Ford EHRs are available as  read-only for outside providers, the Denver Health EHR cannot be viewed  by mental health care providers outside of its system. A Denver Health  official told us that, with the exception of enrollees in Denver Health’s  managed care plans, Denver Health’s patients with severe and persistent  mental illness receive their outpatient mental health care from a  community mental health center in Denver that uses an EHR that is  separate from Denver Health’s EHR. As a result, Denver Health  providers, such as those working in the psychiatric emergency  department, do not have immediate access to information about the  care  their patients received at the community mental health center, which can  affect patient care. However, Denver Health providers do have access to  an electronic database with the prescription history of patients who visit  the community mental  health center.
section_title: IDSs May Experience Challenges in Changing Management and Physician Culture and Implementing an EHR
paragraphs: Officials from some IDSs told us about challenges they faced as their  systems have evolved, in particular, difficulty in changing management  and physician cultures and in implementing an EHR. For example, as  Allina centralized its supervision of clinical care, it redefined the role of its  clinical directors, who used to manage groups of clinical services at  individual facilities. When the system transferred supervision of the  clinical services from the individual facilities to the central system, the  facility clinical directors were concerned that they would no longer have a  role in clinical management and would be responsible for administrative  functions only. The operational challenge was different at Intermountain,  where implementing care protocols required a change in the physician  culture because of the generally independent nature of physicians and  their concern that Intermountain was trying to “tell them what to do.” The  system has been making efforts to motivate physicians to use  Intermountain’s voluntary care protocols for about 10 years. To do so,  Intermountain uses physician-level data to show how individual physicians  are performing relative to their colleagues. Intermountain has more buy-in  from physicians now than in the past, but officials there said changing the  culture continues to be a challenge.
Some IDS officials said that implementing an EHR system is financially  and operationally challenging. For example, NYCHHC currently has eight  separate EHRs that were developed and customized at the subsystem  level, and it has been financially and operationally challenging to  consolidate them into an interoperable system. Because the EHRs were  developed at the subsystem level, clinical data can be shared within each  subsystem, but NYCHHC does not yet have a system that can seamlessly  transfer clinical data across the entire system. According to senior  NYCHHC officials, consolidating the regional EHRs, as NYCHHC is  currently doing for its electronic blood bank registry, is part of the  system’s strategic plan. Henry Ford has also encountered challenges in  implementing its EHR system. Because of cost and connectivity issues, its  school-based health centers do not currently have access to the system’s  EHRs. A Henry Ford official said that the school-based health centers have  competing priorities for funds provided by Henry Ford, including staffing  needs, and that Henry Ford has not been able to pay for the  implementation of the EHR at the school-based health centers but plans to  do so eventually.
We are sending a copy of this report to the Secretary of Health and Human  Services and the Administrator of the Health Resources and Services  Administration. The report also is available at no charge on GAO’s Web  site at http://www.gao.gov.
If you or your staff have any questions regarding this report, please  contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix II.
section_title: Appendix I: Selected Characteristics of Integrated Delivery Systems in GAO Sample
paragraphs: Payer mix (percentage of patient population)
Uninsured Medicaid Medicare Private  Other  2  Some IDSs are organized into multiple subsystems—local or regional delivery systems that are  organized below the system level—that integrate clinical care within themselves. For IDSs organized  at the subsystem level, this table identifies the subsystem we studied for this report and gives the  system name in parentheses.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Helene F. Toiv, Assistant Director;  Anne Dievler; Joanne Jee; Martha R.W. Kelly; Mariel Lifshitz; Kate Nast;  Roseanne Price; Janet L. Sparks; Margaret J. Weber; and Jennifer  Whitworth made key contributions to this report.