Valor actual neto

“In order to continue providing affordable, quality healthcare, governments have no choice but to restructure the health system in ways that enhance efficiency and reduce fragmentation, and integration is a principal driver of reform.” (Health Care Quarterly Special Issue 2009)

Integrated care is not about assembling a number of components and waiting for a specific set of impacts to arise, it is a much more complex set of processes which are influenced and interpreted by a range of different stakeholders. The principle of integrated care is to “provide the right services, at the right time, to the right people at the right place” [Kodner/Spreeuwenberg 2002]. The tricky question remains who defines and who evaluates what is right in this context.

Armitage et al. (2009) state that “[U]nderstanding what is being integrated and for what purpose is necessary in order to identify and implement appropriate models, processes, strategies and structures within the context of population needs.“ Following this argument, the research question of this thesis is to analyse the process leading up to the decision of initiating an integrated care project or programme. In answering the questions of why integrated care is being implemented and what led to the decision for integrated care, it will highlight underlying mechanisms and decision making processes of integrated care.

6.1.1 The Scientific Approach

Integrated care is still a research field in the making and the lack of a common understanding hampers many research efforts. In order to find answers to the research

question a multi-modal approach was chosen where every scientific method represented a specific phase in the research:

• A participative design workshop defined the status quo, common grounds, future challenges to set the frame for the further research. (Chapter 5)

• A literature review on decision making in health care and on evaluation and outcome measurement for health yielded the analytical framework for the research question. (Chapters 2 – 4)

• An expert questionnaire targeted integrated care managers and initiators with items developed from the results of the literature review. (Chapter 6)

• The statistical and qualitative analyses of the responses lead to conclusions on the research question and hypotheses formulated. (Chapters 6 and 7)

6.1.2 Theories and Hypotheses

It is a standing expression in integrated care and health systems literature that the demographic change (i.e. the “ageing societies”), the high costs of service provision and the growing number of chronic and multi-morbid patients are reasons enough to demand new models of care and health care reforms. It is further assumed that integrated care provides all the answers to these problems: with its focus on a comprehensive and interdisciplinary patient management, optimised information, communication and management processes and a cost-effective and high quality service delivery it is supposedly providing better care for less resource utilisation. Hence, the main players and initiators of integrated care projects are health insurance funds, health maintenance organisations, health departments on all levels of public administration and professional organisations, especially primary care providers. It stands to reason that this wide array of integrated care propagators and decision makers have their own and maybe differing reasons why to start and invest in such an endeavour.

This thesis aimed at clarifying the more specified aims and expectations of integrated care initiators and managers. The hypotheses behind this task were:

1. Even though integrated care projects and programmes are implemented in very different settings and health systems one can find the same main actors

everywhere. They share similar goals and principles, which are universal and not unique to one specific country or system. Hence, it is likely that the type of actor, i.e. health insurance, is more influential on the decision making process than the health system and surrounding setting. In other words, it is here stipulated that a health insurer in the Netherlands will have similar priorities for integrated care as

a health insurer in Singapore and hence will choose similar integrated care approaches.

2. On the other hand side, system administrators can strongly incentivise or discourage innovation and cooperation within the health and social care dominions, i.e. by passing laws or (re)organising the financing system. It is suggested that integrated care is implemented more widely in countries where stakeholders receive targeted incentives and fragmentation within the system is less pronounced.

3. The introduction of a formalised performance measurement plays no role in the decision making process.

These hypotheses were tested with an expert questionnaire, which comprised open and closed questions as well as a list of criteria often used to describe the fields of health and social care. The items on this list were to be rated according to their importance for the initiation and planning of the integrated care project/programme in question. The final outcome drew a picture of the most important influencing factors and priorities of decision makers in integrated care. These results provided the answers to the research question of what causes decision makers to engage in an integrated care project and which priorities lie beneath this decision.