Integrated Health Care: International Experience and Its
       Relevance for the Russian Health System


                   Author: Igor Sheiman




                        June 2019
Contents
Executive summary ................................................................................................................................. 3
1.      Introduction ..................................................................................................................................... 5
2.      Definitions, characteristics and tools related to integration ............................................................ 6
3. Integration tools .................................................................................................................................. 9
     3.1 Strengthening of the role and coordinating function of the primary care doctor .......................... 9
     3.2. Development of the forms of vertical and horizontal interaction between healthcare providers 11
     3.3. Development of integrated models for managing patients with chronic and multiple diseases . 16
     3.4 Intensification of information exchange between healthcare providers ...................................... 20
     3.5 Development of integrated pathways for healthcare delivery and efficient referral system ....... 23
     3.6. Development of economic incentives to ensure closer interaction between healthcare
     providers............................................................................................................................................ 24
4.      Management of the integration process......................................................................................... 28
Conclusions ........................................................................................................................................... 30
Literature references.............................................................................................................................. 30




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Executive summary
        This policy note has the objective to highlight the international integration tools to
strengthen teamwork, coordination and continuity of health care and develop recommendations
on their use in Russia. The major criteria for the choice was their relevance for the Russian
health system. The list of instruments includes:
        1) strengthening the role and coordinating function of primary care physicians;
        2) development of the forms of vertical and horizontal interaction between health
           providers;
        3) development of integrated models for managing patients with chronic and multiple
           diseases;
        4) intensification of information exchange between providers;
        5) development of integrated pathways for service delivery;
        6) development of economic incentives though new provider payment methods.

Strengthening the role and coordinating function of primary health care (PHC) physician is
one of the most important pre-condition for integration. In Russia, coordinating and
gatekeeping function of PHC doctors has weakened recently as the result of a substantial
shortage of district physicians. The current attempts of the Government to cope with their
shortage under the National Health Priority Project should be complemented with a set of
integrative activities, including:
   •   Re-vitalization of referrals to specialists.
   •   PHC physicians’ training on their role as coordinator.
   •   Inclusion the function of coordinator in PHC physicians’ job description.
   •   Development of regulation ensuring that district physician not only refers patients to
       specialists but also recommends the most appropriate providers, overviews the results
       of a specialist visit and explains the following steps of a patient, plans curative activities
       together with specialists.

Development of the vertical and horizontal integration between health care providers. In
Russia, concentration of health care providers is not always accompanied with actual integrative
activities. To strengthen the impact of provider concentration on vertical and horizontal
integration, it is recommended to enhance the level of medical and economic justification for
making decisions on the unification of health providers with a focus on ensuring actual
integrative activities. Specific forms of integration with a focus on the interaction between
polyclinics and hospitals should be developed, including:
    • provision of information to polyclinics on all hospitalizations in the catchment area to
         ensure subsequent after-discharge treatment;
    • joint development of a hospital discharge planning procedure, provision of the
         necessary information to polyclinics for timely follow up and management of patients
         after discharge from the hospital;
    • arrangements for regular consultations to be provided to polyclinic physicians by
         hospital doctors, training sessions;
    • improving communication regarding the justification of referrals to hospitalization and
         pre-admission diagnostic procedures;
    • improving communication between polyclinic and hospital doctors regarding
         complicated cases;
    • involvement of polyclinics in planning of inpatient care.

Development of integrated models for managing patients with chronic and multiple diseases.
The international chronic disease management programs are explored and compared with
similar arrangements in Russia with the conclusion that the Russian programs are limited in



                                                 3
scope and lack some activities. Given their limitations, the following activities are
recommended:
    • Setting-up chronic patients’ registration system with risk stratification.
    • Organization of multidisciplinary teams for patient management.
    • Appointment of disease management program coordinator. The best option is a general
      practitioner or district physician (pediatrician).
    • Conclusion of agreements between chronic patients and providers.
    • Promotion of proactive prevention and managing of chronic conditions.
    • Establishment of algorithms for PHC doctors’ actions immediately after the
      hospitalization of complicated patients, assignment of doctors responsible for their
      follow up.
    • Establishment of contacts between PHC doctors and hospital doctors.
    • Improving communication with the relatives of acute patients.
    • Monitoring process and outcomes of activities.

Intensification of information exchange between healthcare providers. Health care data
integration is considered a cornerstone of every systematic attempt to achieve integrated patient
care. Data integration has the potential to provide multiple stakeholders with critical, timely,
and detailed information for short- and long-term decision-making, documentation, and it
supports attempts to achieve structural and functional health care coordination and integration.
The international experience of organizing information exchange is presented and compared
with Russian practices with the following recommendations:
    • The model of health care organization should be first specified with the following
        development of IT system to serve it – not on the contrary, which is the case in Russia.
    • The detailed planning and ongoing assessment of health care data integration is needed
        to ensure accurate and effective coordination of information.
    • The integration of information requires common rules for its use: clearly specified
        actions of doctors in regard to patients, especially those with particularly high risks.
    •   Arrange additional forms of information exchange, including feedback of specialists
        after consultation, provision of information on admissions and ambulance calls to
        district physicians, on-line consultations, control of recommendations implementation
        after hospital discharge by polyclinics physicians.

Development of integrated pathways for service delivery. In Russia, the pathways exist but
they mainly aim at determining the requirements for health care resources. Given the
international experience, it is important to consolidate the integration component of pathways
with a focus on ensuring comprehensiveness and continuity of care. It is recommended:
    • Include in the pathways the algorithms of interaction between individual providers to
        ensure continuity of care at various stages of service delivery.
    • Include process and outcome indicators.
    • Ensure compliance with algorithms and indicators in the quality control activities.
    • Expand the scope of quality reviews conducted by health insurance organizations. The
        review should focus on quality of post-hospital care and continuity of treatment at
        different healthcare delivery stages.

Development of economic incentives to ensure closer interaction between health providers.
Capitation model complemented by pay for performance payments, episode-based bundled payment and
global budget are highlighted as the options for Russian health care system based on the international
evidence. The following models are recommended for Russia:

    •   Introduce pay-for-performance for polyclinics to complement the current capitation
        payment method to promote: a) development of chronic disease management activities,




                                                  4
       b) more intensive information exchange between physicians, c) coordination function
       of primary care providers, d) effective after-discharge clinical activities.
   •   Develop bundled payment rate for inpatient care and medical rehabilitation for the
       specified period of time after hospital admission.
   •   Establish a managerial control of services under global budget, including the enrolment
       of patients, a sound referral system, a careful specification of the services under global
       budget, measuring the input of each provider.


   1. Introduction

       Over the past two decades, there has been a notable growth of interest in integrated
healthcare delivery globally. Concrete integration programs have been developed and are
underway in the U.S.A. and most European countries. The results of their implementation are
being extensively discussed in literature on health economics and management. The World
Health Organization presented the Global Strategy of People-Centered and Integrated Health
Services. The International Foundation of Integrated Care was established to focus on the
matters related to the integration of efforts of various healthcare providers.
       The increasing attention to the issue is due to numerous traits of healthcare
fragmentation. The key fragmentation traits include inadequate coordination of the activities of
individual providers, low level of teamwork, lack of focus on ensuring continuity in medical
treatment at various stages of the medical and technological cycle. According to the results of
a population survey in 11 European countries, over 10% of patients report that they have been
faced with the problem of contradictory recommendations from different doctors. 40% of
hospitalized patients stress lack of treatment continuity after hospital discharge (i.e. inpatient
and outpatient doctors do not properly coordinate their work), 20% of patients state that their
permanently doctors are not aware of their hospitalizations (Nolte, 2017).
       Fragmentation of the activities of healthcare providers has turned into a serious
challenge for the healthcare governance system in developed countries. Copying with
fragmentation and shaping an integrated healthcare system has become an independent area
of government policy.
       The Russian health system also features processes related to the fragmentation of
healthcare. There is empirical evidence of the lack of coordination between the activities of
individual providers and medical workers. The health system loses significant funds at the
“interface� between such providers due to their lack of focus on teamwork and overall
performance (Shevsky et al., 2013). In recent years, certain positive processes have emerged,
which consolidate the interaction between healthcare providers. The most important of them
are the establishment of a unified information system, development of a multi-tier healthcare
system, and the formation of united medical systems. All of them are worthy of further



                                                5
development but the variety of integration activities is still rather limited, and some of the
organizational and economic integration mechanisms already proven abroad are still unknown
in Russia.
        The purpose of this paper is to present the most interesting integration tools used in
developed countries and discuss the opportunities for their use in the Russian practices. The
first section provides the definition of integration, identifies its key characteristics and tools.
The second section presents the tools with recommendations for their practical use in the
Russian health system. The third section outlines the role of governance and regulation in this
area.


    2. Definitions, characteristics and tools related to integration

The concept of integrated care in its most general form is defined as “a coherent set of
methods and models on the funding, administrative, organizational, service delivery
designed to create connectivity, alignment and collaboration within and between the cure and
care sectors.� (Kodner and Spreeuwenberg, 2002)1.
        The WHO European Bureau refined this definition by referring to the need to “combine
the services relating to diagnostics, treatment, care, rehabilitation, and promotion of a healthy
way of life� (WHO, 1996). This definition focuses on the medical and administrative aspect of
the activities – collaboration and cooperation of healthcare providers and various medical
professions targeting the achievement of a higher ultimate result in the treatment and prevention
of diseases. But in addition to the above aspect, the notion of integration includes financial and
managerial mechanisms intended to strengthen the interaction between separate healthcare
providers.
        The notion of integrated care has not yet asserted itself in the Russian literature on
healthcare while it is totally missing in statutory regulations. That is largely due to the prevailing
idea that the problem is not very relevant for Russia since integrated care is already a part of
the existing health model. And there are certain reasons for such a mindset. The traditional
Semashko model (that is how the Soviet public health system is referred to in the western
literature) distinguishes the following vital elements of integrated healthcare (Semashko, 1947):
              − care delivery based on health districts, district doctor’s responsibility for the
                   health condition of the continuously observed population;
              − joint work of different medical professions in the framework of a multi-profile
                   polyclinic;



        1
            Translated from Russian



                                                  6
           − multi-tier care delivery, with each tier corresponding to a certain level of disease
               severity;
           − government administration of the system making it possible to establish forms
               of interaction between separate healthcare providers.
       The key integrator in the theoretical model by Semashko is the local district doctor who
does not only treat patients him/herself but also organizes and coordinates healthcare at other
stages of its delivery. He/she continuously follows up the district population, and ensures the
continuity of treatment at various stages. A multi-tier healthcare structure and coordinating
function of the district doctor – these central ideas of Semashko’s model are being widely
analyzed and promoted today in western literature as important elements of the integrated
system even though Russia’s precedence in these integration elements has already been to a
great extent lost, as will be shown in continuation.
       Modern Western literature picks out similar and additional characteristics of integrated
care. For the particularly fragmented U.S. health system, well-known American economist A.
Enthoven distinguishes the following features of integrated systems: a) teamwork aimed at
connections with other healthcare delivery elements and attainment of the ultimate result of
patient management; b) coordination and information exchange between different medical
professions; c) measuring the activities of selected healthcare providers, and performance
accountability; d) keeping track of patient’s movement between healthcare providers, as well
as of the patient’s condition and volume of services received. There is a special emphasis on
the principle of shared responsibility for the entire medical and technological cycle of patients'
management. In the fragmented model, the primary care physician usually “loses� his/her
patient after referral to a specialist. In the integrated system, the physician coordinates the
patient’s movement to specialists with subsequent feedback. Such model enhances the ultimate
treatment results as the patient is under control of one doctor or healthcare coordinator at all the
stages (Enthoven, 2016).
       Integrated systems feature a change in the proportion between inpatient and outpatient
care. Hospitals are increasingly regarded as cost centers rather revenue centers. An increase
in the number of hospital admissions in the emerging integrated systems is a sign of poorly
developed outpatient care so best efforts are being made to strengthen it. In equal measure,
there is a focus on increasing treatment continuity in various parts of the system – it helps to
reduce the costs relating to their estrangement and ensure a higher ultimate treatment
performance.
       D. Berwick et al. (2009) distinguishes the following integration characteristics:
       a) responsibility of a group of healthcare providers for particular population (i.e.
repeating Semashko’s central message);



                                                 7
       b) work based on a fixed budget allocated for continuously observed population, which
creates strong incentives for the search of intra-system sources of savings;
       c) introduction into the system of an «integrator� – a healthcare provider undertaking
the responsibility for delivering healthcare to a particular group of population;
       d) education of chronic patients, continuous communication with them;
       e) a shift from individual medical practices to collective forms of primary care delivery,
with the involvement of specialist doctors and close cooperation with hospital departments.
       D. Cortese and R. Smoldt (2007) supplement it with closer ties between the outpatient
doctor and hospital, and integrated methods of healthcare financing based on payments for
bundles of interrelated services rather than for isolated services. A paper by Ð?. Somanathan
(2018) distinguishes six key tools: reorganization of care providers to implement the principles
of patient-oriented healthcare; shaping of an information infrastructure for data exchange;
monitoring healthcare providers and feedback tools; involvement of patients in healthcare
delivery, financial incentives for joint work; training of medical workers capable of working in
interdisciplinary teams.
       Based on the above mentioned papers, we distinguish three summarized integration
characteristics: 1) joint efforts of various medical services, 2) coordination of their actions, 3)
continuity in healthcare delivery. These characteristics most fully describe the process of
integration: the setting-up of interdisciplinary teams of healthcare providers operating on the
basis of shared clinical recommendations; they interact with each other to achieve a higher
clinical result; each phase of patient’s management is linked to the previous and next phase. To
attain the above characteristics the following most important integration tools are used:
           1. strengthening of the role and coordinating function of the primary care doctor;
           2. development of the forms of vertical and horizontal interaction between
               healthcare providers;
           3. development of integrated models for managing patients with chronic and
               multiple diseases;
           4. intensification of information exchange between healthcare providers;
           5. development of integrated pathways for healthcare delivery and efficient referral
               system;
           6. development of integrated payment rates for a package of interrelated types of
               healthcare.
       The list of such tools can be supplemented but we have singled out those which are most
essential for the practice of the current health system in Russia.




                                                8
3. Integration tools
3.1 Strengthening of the role and coordinating function of the primary care doctor
       Many international researchers emphasize the special role of the general practitioner as
the system’s gatekeeper referring patients to specialist physicians and for hospitalization (as
opposed to the model of direct contact with specialists). Such doctor acts as patient’s agent
setting up medical and technological links in the multi-tier health system. Empirical proof has
been accumulated, which shows that in countries where general practitioners perform
gatekeeper functions in health system, more attention is attached to joint work and continuity
of care (Calnan et al., 2006). Moreover, a certain pattern has been identified: in the OECD
countries where general practitioners refer patients to specialists and perform the coordinating
function, the volumes of inpatient care and total healthcare costs are lower thus ensuring cost
savings (Sheyman, Shishkin, 2012).
       An attitude is growing up that the goals of enhanced integration can only be achieved if
there is a permanent “list of patients� (Kringos et al., 2015), or using the terminology adopted
in Russia – through the use of the district-based primary care delivery. Only this kind of
arrangement can ensure the responsibility of district physician for the health condition of
continuously observed population.
       It is noteworthy that the highest attention to the role of coordinating function of primary
care is currently reported in the U.S.A. where traditionally the population has not been attached
to a particular general practitioner, and there is a shortage of such doctors up to date. Emerging
integrated systems impose increasing requirements for coordinated healthcare delivery,
providing for more intense interaction between individual providers and reduction in the time
it takes to find an appropriate provider. Table 1 gives an example showing the differences
between coordinated and non-coordinated healthcare in the real practice of the U.S. health
system.
       Table 1. Comparison of coordinated and non-coordinated care models in case of
suspected breast cancer in the U.S.A.
  Patient management         Coordinated healthcare                         Non-coordinated healthcare
            phases
                             GP issues a referral. His/her office workers   GP issues a referral. The patient
          Referral for
                             prepare a timetable and find an appropriate    herself searches for a care provider.
      mammography
                             care provider.
                             GP receives mammogram results and makes        Next appointment is not made. In
                             another appointment. The patient is provided   the best case, a general practice
   Subsequent visit to the
                             with information about her condition, if       worker informs the patient over
    general practitioner
                             needed biopsy is recommended. Information      phone of the need for biopsy after
                             is provided about the available surgeons as    receiving mammogram results.




                                                    9
                                well GP’s role as the patient’s medical
                                advocate.
                                The general practice worker helps the patient    The patient looks for a surgeon
    Referral for biopsy
                                to select a surgeon, and books an appointment.   herself and books an appointment.
                                The results of diagnostic tests and necessary    The test results and information
   Information exchange
                                information regarding the patient’s health       about the patient are sent to the
    between the general
                                condition are sent by the general practice       surgeon upon his request. The
    practitioner and the
                                worker to the surgeon before the patient’s       biopsy results are not sent to GP.
          surgeon
                                visit. The biopsy results are sent to GP.
                                Upon receiving the results from the surgeon,     The patient herself selects the
  Informing the patient of
                                an extra GP appointment is made to provide       treatment using surgeon’s
    the likely treatment
                                the patient with information about all the       recommendations.
          options
                                possible treatment options.
                                Treatment planning is done by GP/coordinator     Treatment planning is done by the
                                jointly with the patient.                        patient herself after visiting various
    Treatment planning                                                           specialist doctors and taking into
                                                                                 account their recommendations
                                                                                 (which do not necessarily match).
       Source: Stille et al., 2005 (adapted)
       In the above example, coordinated healthcare focuses more on patient’s needs, and
reduces the waiting time before the start of cancer treatment. Thereupon, the likelihood of
positive treatment outcome increases.
       Also interesting are the tools increasing the role of primary care physicians (Rice, 2011;
Keshvani, Walsh, 2013; Essential hospital institute, 2013):
   •   involvement of these doctors in the medical direction of hospital systems. They are given
       the leading role in the organization of closer interaction between doctors from outpatient
       clinics, hospitals, and rehabilitation centers providing for appointments with discharged
       patients, follow-up treatment in the outpatient setting, with an overall responsibility for
       the outcome;
   •   establishment of a healthcare quality management system shared by medical practices
       and hospitals, including: a) adaptation of the existing clinical recommendation and
       standards to the particular care provider environment; b) creation of a common reporting
       system based on “composite� clinical activity indices (rather than separately for
       hospitals and medical practices; c) creation of individual doctor records to detail the
       volume and structure of their clinical activity, degree of complexity, and clinical
       outcomes; d) regular discussions of the clinical practice involving doctors from related
       medical services;
   •   participation of major general medical practices in planning of inpatient care volumes.




                                                       10
       In the Russian context, the activities aimed at increasing the district doctors’
coordinating function are vital. It is only possible based on the consolidation of the above
mentioned “gatekeeper� principle, which is eroding in recent years. According to the surveys
of district doctors conducted by the National Research University Higher School of Economics
at the end of 2016, 83% respondents believe that the patients from their districts apply directly
to obstetrician/gynecologist, 75% - to urologist, 70% – to ophthalmologist, 69% - to ENT
specialist and dermatovenerologist, 35% - to neurologist, 22% - to cardiologist (Sheiman et al.,
2019). Without restoring the patients’ referral system, it is difficult to ensure the coordinating
function of the district doctor.
       It is important to note that limited coordination functions of district physicians is the
result of the acute shortage which amounts to around 30 % pf district therapists (adult care) and
10% of district child care doctors (Sheiman et al, 2019). Currently, there are activities to cope
with this shortage under the National project “Health care�. They should be complemented with
the activities to strengthen the coordination role of primary care providers.
       Training of general practitioners should focus not only on their mastering some of the
functions of specialists but also on the implementation of coordinating work as well. Such
doctors should become the key integrators of healthcare accumulating all the information about
the services provided to “their� patients, and acting as their representatives for healthcare
delivery at other stages. They should turn into a kind of patients’ “pilots� in a shoreless sea of
medical technologies and services.
       It is worth mentioning that the typical job descriptions and other statutory regulations
on the activity of primary healthcare doctors in Russia do not mention the district doctor’
coordinating function at all. The district doctor has been long regarded as a specialist in a limited
number of trivial diseases. His/her clinical functionalities should be broadened (as recognized
today), however, there has been no talk of such doctor’s central role in healthcare organization
– in the way it was originally stipulated in Semashko’s model but then practically disappeared
under the influence of excessive specialization of primary healthcare.

3.2. Development of the forms of vertical and horizontal interaction between
healthcare providers

       Horizontal interaction is carried out between healthcare providers of the same level i.e.
between district doctors and outpatient specialists, between physicians from curative and
diagnostics divisions of polyclinics. Vertical interaction is based on strengthening the relations
between healthcare providers of different care delivery levels, e.g. between polyclinics and
hospitals, rehabilitation centers etc. The development of such interaction can be achieved
through concentration of healthcare providers – their mergers, and formation of hospital



                                                 11
complexes and outpatient-inpatient systems. However, it is also possible to consolidate
networking interaction based on contracts or informal agreements.
       Recent years have seen a growth in concentration processes among healthcare
providers in Western countries. In 2000-2010, there were 640 hospital mergers in the United
States (Schmitt, 2017). The share of medical practices owned by hospitals grew from 30% of
the total number of practices in 2004 to 55% in 2009 (Stacey, 2012). Similar processes are
underway in the UK and France (Gaynor et al., 2012; Nolte, 2014). Integration processes have
intensified within major healthcare centers. Healthcare quality management systems shared by
medical practices and hospitals are being set up. Procedures are being established to regulate
the actions of doctors of different levels, including compulsory information exchange between
them. Interdisciplinary teams made up of physicians and nurses are being formed with the
participation of hospital doctors to manage patients with chronic and multiple diseases. To
encourage integration, bundled payment rates are increasingly used, which are calculated per
person choosing the integrated system.
       Increased interest has been reported in large-size forms of primary healthcare. The
process develops along two vectors. The first vector consists in the unification of individual
medical practices and formation of polyclinic-type entities. General medical practices include
social workers, psychologists, 2-3 categories of specialist doctors, and several categories of
nursing staff (Kringos et al., 2015). But the level of unification is incomparable with the model
of the Russian urban multi-profile polyclinic with 17 to 20 specialists gradually replacing
district doctors. The trend towards bundling of primary healthcare providers in Western
countries does not yet imply borrowing the Russian polyclinic model. Such polyclinics are
operating in a limited number of countries but with a few exceptions (e.g. in Finland) they are
not the key form of primary care organization.
       The second vector is the establishment of medical practice networks operating based on
formal and informal arrangements, e.g. in England (Iacobucci, 2019). Interest towards them is
growing in many Western countries. However, the principle of independent individual and
group practice is not questioned. Their ultimate responsibility for the health of the catchment
area population is still outweighing the opportunities offered by teamwork in the framework of
large organizational structures. The former already exists, while the latter requires special
integration activities to be carried out.
       The empirical assessments of the efficacy of the formation of large integration systems
are rather contradictory. Shortell and Schmittdie (2004) demonstrated closer links between
outpatient practices and hospitals, and a wider spreading of chronic disease management
programs in major integrated systems in the U.S.A. A systematic review of research on the
U.S.A. conducted by Hwang, et al. (2013) showed that 19 out of 21 articles on concentration



                                               12
efficacy revealed a higher healthcare quality and lower unit cost of hospital stays (per patient)
in integrated systems compared to independent healthcare providers with fee-for-service
payment. However, these results are opposed by other surveys. Dranove and Lindrooth (2003)
showed that large associations of local hospitals in the U.S.A. achieved short-term reductions
in the administrative cost but it had no effect on the general costs and medical care quality
compared to independent hospitals. Kaul et al. (2016) did not discover any relationship between
the size of integrated systems (with 520 associations reviewed) and the unit cost under the
Medicare and Medicaid programs in the U.S.A. Similar conclusions were drawn in the studies
on the UK (Fulop, 2002; Posnett, 1999).
       The authors explain the absence of relationship by the fact that many associations are of
a formal nature. Branch providers are frequently guided by their own rules, and are not an
organic part of integrated systems. To strengthen interaction between service providers, it is
necessary to implement actual integration activities rather than formal mergers. In the absence
of such activities, other factors get the upper hand such as the complexity of managing large
complexes, reduced level of competition, slackened economic incentives for certain divisions
of the formally integrated system.
       The concentration process of healthcare providers in Russia has also intensified over the
past decade. Polyclinics have been merging with hospitals. At present the share of independent
polyclinics accounts for mere 36% of their total number (49% in 2000), the others operate as
part of combined hospitals. In 2000-2014, the number of independent healthcare providers went
down by 60%. The number of hospitals decreased by more than a half, and the number of
outpatient polyclinics – by 35% (Sheyman, Shevsky, 2019). In a number of regions, e.g. in the
Moscow Oblast, large healthcare complexes are being formed to include practically all
territorial healthcare providers. In fact, they use the same pattern as hospital systems and
inpatient-outpatient associations in western countries. In 2012, all Moscow polyclinics were
united into large outpatient centers – 5 to 7 polyclinics in each center.
       The main positive result of concentration is the increased opportunity to handle the
resources. The centralized level is used to tackle issues related to restructuring providers
network – to close small and inefficient institutions, centralize scarce resources, regroup certain
medical services to ensure more effective use of resources. It is logical to suppose that the
concentration is to result in boosting teamwork, coordination and continuity of healthcare
delivery since the administrative unity environment allows developing a closer interaction of
individual providers. But our estimates do not confirm the hypothesis. A survey of the leaders
of 4 polyclinics and 5 hospitals in Moscow based on a common questionnaire showed that when
preparing a patient for hospitalization polyclinic doctors rarely align their actions with those of
hospital doctors; hospital doctors in their turn extremely seldom advise polyclinic physicians



                                                13
regarding patients’ management tactics after hospital treatment. All of the surveyed chief
medical officers from hospitals unanimously assessed as unsatisfactory the general level of
interaction between the staff of hospitals and polyclinics. A comparative analysis of the level
of integration in the environment of independent polyclinics and combined hospitals based on
the survey of 1,500 from 13 Russian regions showed that combined hospitals had no advantages
in terms of teamwork, coordination and continuity of care. Neither do such advantages exist for
large territorial healthcare complexes (Sheyman, Shevsky, 2019).
       International and domestic experience shows that it is essential to “fill� provider
concentration with actual activities towards the integration of individual providers performance.
Functional integration, i.e. the consolidation of interaction between healthcare providers,
should be given a higher priority compared to organizational integration. The following
specific recommendations relating to the management of concentration processes can be
suggested:
       1. Enhance the level of clinical and economic rationale for making decisions on the
unification of healthcare providers with a focus on ensuring a true integration of the operation
of its separate elements. It is necessary to identify the existing fragmentation areas in the work
of: a) separate polyclinic divisions, b) polyclinics and hospitals, c) polyclinics and first aid
stations/emergency wards, d) hospitals and after-treatment/rehabilitation services, e) treatment
departments and diagnostics departments. Collect and analyze information on the extent of
continuous observation of patients as well as the appropriateness of the existing care pathways
of patients between individual providers. It is important to determine whether it is possible to
overcome fragmentation using the efforts of management bodies without formal unification.
        2. When deciding on the appropriateness of unification of healthcare providers it is
necessary to take into account their location. Such unification is justified if low capacity
healthcare providers are located relatively close to each other. In such a case, it will be easier
to build rational clinical pathways of patients. If the unification exceeds an optimal size, or the
branch offices are located far away from each other, then the anticipated consolidation of
interaction between the polyclinic and hospital can be counter-balanced due to the complexity
of managing such a complex. Adverse implications are also possible for the accessibility of
medical care: the distance to be covered to receive a particular service may prove unacceptable
for the population.
       3. Develop specific forms of interaction in the framework of the healthcare complexes
and individual divisions. Particular importance is attached to the following interaction types:
Between polyclinics and hospitals, including specific activities:
-      provision of information to polyclinics on all hospitalizations in the catchment area to
ensure subsequent after-discharge treatment (and at the polyclinic level – to district physicians);



                                                14
-          joint development of a hospital discharge planning procedure, provision of the necessary
information to polyclinic district physicians and specialists for timely after-treatment and
management of patients at outpatient centers;
-          arrangements for regular consultancies to be provided to polyclinic physicians by
hospital doctors, training sessions;
-          provisions for communication regarding the justification of referrals for hospitalization
and a set of necessary tests;
-          provisions for feedback between polyclinic and hospital doctors regarding complicated
cases.
           It is particularly important to ensure the involvement of large polyclinics in planning
inpatient care volume and control of its delivery. In our opinion, the planning algorithm for
inpatient care volume planning should include the stage of the assessment by polyclinics of the
need for inpatient care of the continuously observed population, as well as their choice of
hospitals with steadily higher performance. It requires a large volume of information that
should be intimated to the polyclinics by health system governance bodies and territorial
compulsory health insurance funds. At the same time, it is appropriate to grant the right to
polyclinics to monitor the progress of hospital treatment, without interfering in the therapeutic
component but supervising the treatment process administration, e.g. the timeliness and
justification of extra diagnostic tests, LOS, completeness of hospital discharge summary with
a breakdown of after-treatment care, etc. Random reviews to be conducted by polyclinics can
become more useful than reviews conducted by health insurance organizations, because
polyclinics are keen on receiving a well cured patient rather than on “punishing� hospitals with
financial penalties. As demonstrated by international and domestic experience (Samara’s
experience in the 1990s), it is impossible to implement this mechanism using exclusively
administrative measures. It requires a strong economic motivation of polyclinics (see Para. 2.5).

Between polyclinics and ambulance care/emergency wards:
    - provision of information to the polyclinic about all the ambulance calls by the polyclinic’s
catchment area population, communication of this information to each district doctor;
- provision of information to the polyclinic about the results of diagnostic tests, preliminary
diagnoses, and medical interventions.
Between polyclinic departments:
    -      provisions for joint management of patients by district physicians and specialists;
-       on-going monitoring of continuity performance during patients' management;
    -      improvement of feedback between specialists and district doctors based on the results
of consultations.




                                                  15
3.3. Development of integrated models for managing patients with chronic and
multiple diseases

       A special role in the concept of integrated healthcare is played by chronic disease
management programs widely spread in many countries in response to a growth in the
prevalence of chronic and multiple diseases. An increasing number of people survive to the age
when such diseases develop. New medical technologies emerge that make it possible to improve
the results of their treatment.
       Chronic disease management programs (CDMPs) comprise integrated activities aimed
at comprehensive treatment over a long period of time: formation of interdisciplinary teams of
medical workers, provisions for the alignment of their actions, preparation of individual plans
of patients' management and continuous monitoring of their progress, use of integrated
procedures for healthcare delivery, involvement of patients in the treatment process, use of
economic incentives for joint work and attainment of ultimate results. Strictly speaking, these
programs are a comprehensive integration tool, which includes all of the above listed
approaches.
       An example of comprehensive actions in patient management is provided by stroke care
programs in the Netherlands (Vat et al., 2016). These programs aim at improving the quality of
life for patients who had stroke and reducing the likelihood of disease recurrence. The small
country is implementing 75 such programs. Each program enrolls general medical practices,
hospitals, rehabilitation centers, nursing care centers, independent visiting nurse groups. An
average interdisciplinary group includes seven doctors of different specializations. Each group
manages 495 stroke patients.
       The program is coordinated by a general practitioner (sometimes another specialist).
The coordinator is responsible for establishing interaction with patients, and for the treatment
process. It is important that doctors participating in the groups are not relieved from their routine
treatment work. It is estimated that they spend an average of nine hours per week on the work
in the program. Almost all the groups operate based on contracts. If a hospital doctor is hired,
a contract is signed with the hospital concerned.
       All of the program participants have to comply not only with general clinical
recommendations but also with the recommendations developed specifically for CDMPs and
accepted by all the participants. It means that a certain variation of clinical recommendations is
possible provided they are approved and subsequently complied with.
       One of CDMP versions is multiple disease management programs. 101 such programs
were underway in Western Europe in 2015 (Rijken et al., 2016). They also provide for the




                                                 16
formation of multi-profile groups and interdisciplinary cooperation. The keystone of their
implementation is ongoing rather than sporadic follow-up of patients with a special role played
by healthcare coordinators. This function is most often performed by general practitioners. The
use of advanced nurses as coordinators has been increasing. To follow up patients with
particularly complex multiple problems case managers are appointed, and the need for them is
growing. Case managers are involved in 40% of European programs. All the programs include
individual patient management plans and their training. Interdisciplinary cooperation is ensured
based on shared electronic health records and periodical meetings of program participants.
       A special emphasis is laid on the dynamic nature of actions in patient management
groups. Physicians and nurses do not wait for the patient to come to see them but are themselves
looking for a contact with the patient using electronic tools and remote patient monitoring tools.
       Multiple disease management groups are usually set up on the functional basis without
formally uniting the participants. Only in 19% of studied programs several organizations were
merged (Rijken et al, 2016).
       Some programs make an emphasis on patients involvement in disease management. The
major instrument is a formal agreement with a patient, which sets the requirements for patients
to comply with an individual plan of treatment and physicians’ prescriptions, see them within
a stated interval, follow the established pathway of patients movement in a multi-level delivery
system. Sometimes economic incentives are used. In France, patients with serious chronic
diseases are exempt from copayment, provided they follow a clinical protocol developed by a
treating physician (Ettelt, 2009).

       The performance of CDMPs and multiple disease management programs has been in
the focus of a large number of studies. A literature overview on the subject conducted by E.
Nolte (2017) showed that 65% of the researches revealed a positive input of the programs in
the achievement of higher clinical performance, 67% provided for increased patients’
satisfaction with the state of healthcare, but only 17% reported cost savings. A significant
positive result has been reported in connection with the measures aimed at establishing
interdisciplinary groups, clinical activity coordination, more frequent contacts between
specialists as well as the implementation of shared information systems to ensure the
coordination. In other words, the programs concerned have a strong effect on the clinical
performance but their contribution in achieving system-based savings has not yet been proved.
       The latter aspect can be explained by the fact that the programs provide for an increase
in the volume of clinical activities aimed at patient management as well as patient care
activities. They require additional investment, which will only pay back with a delay in time.
The first stage of such programs is mainly of extensive nature. A more significant economic




                                               17
effect can be expected in some future. It also important to note that the cost-effectiveness
calculation methodology is still far from being perfect.
       To what extent are CDMPs relevant for the Russian health system? What are the new
things they offer? A typical feature of the Russian health system is the availability of a system
of “dynamic case follow-up�, which contains many elements of western CDMPs. The system
was established back in Soviet times as part of Semashko’s model. In this country, priority was
given to active work with chronic patients earlier than in the West. However, improving this
work is an urgent task for the Russian health system. It above all applies to the scale of work
with patients, and the content of medical and organizational activities.
       The key regulation on this issue is Administrative Order of the RF Ministry of Health
“On the organization of dynamic case follow-up� No.1344n dated 21.12.2012, which sets out
a patient management procedure. But not all treatment activities contained therein are being
implemented in real life. A study conducted by “Rosgosstrakh-Meditsina� health insurance
company based on the results of discipline-related reviews obtained the data on the content of
case follow-ups before and after acute coronary syndrome (ACS) and acute cerebrovascular
accident (ACVA) (Round Table Panel, 2018).
       Insurance representatives of the company surveyed 7,043 patients with ACS and
ACVA, and the results revealed the following assessments of case follow-ups by the patients
themselves:
       • 45% of patients had been undergoing case follow-up for a cardiovascular disease
(CVD) before developing ACS and ACVA;
       • 36% of them were not included in the notified case-list after ACS and ACVA;
       • 19% were not referred by their prescribing physician for the checkup recommended
by hospital doctors;
       • 48% were not referred for consultations to cardiac surgeons, neurosurgeons,
endovascular diagnostics and treatment doctors even though it had been indicated and stated in
the hospital discharge record;
       • 53% were not referred for medical rehabilitation by their prescribing physician;
       • 41% would like to be referred for rehabilitation but did not get a referral.
       The above data show that: a) nearly half patients with a high risk of complications
(primarily, those with arterial hypertension) had not been followed up by doctors before the
onset of a “disastrous� condition; b) over one third of patients after hospitalization for ACS and
ACVA were not included in the notified case-list, to say nothing of providing supportive
therapy; c) half the patients did not receive the required specialists’ consultations and
rehabilitation treatment i.e. the continuity of treatment was disrupted after hospitalization; d)




                                               18
some of the district doctors do not know anything at all about such cases in their district. It is
quite evident that such level of case follow-up cannot be considered sufficient.
       A comparison between international CDMPs and the activities set out in Administrative
Order No.1344n allows singling out the following differences:
   •   CDMPs make a point of continuous follow-up, and the Administrative Order focuses
       on sporadic follow-ups.
   •   A different level of responsibility. Additional consultations and procedures are provided
       for but after conducting them a specialist can forget about the patient. E.g. in case of
       ischemic heart disease two cardiologist’s consultations per year are prescribed. Once
       such consultations are conducted, cardiologist’s management of the patient is over.
       He/she is not responsible for what happens next. However, under CDMPs specialist
       doctors are included in the corresponding groups where they work and are responsible
       for the results along with other doctors.
   •   The Administrative Order does not contain any treatment performance criteria. All the
       treatment efficacy criteria described there are process criteria rather than outcome
       criteria. They are articulated in terms of clinical actions by physicians, which is clearly
       not enough for assessing their work with the group of patients.
   •   The Administrative Order does not describe the organizational models of chronic patient
       management: how exactly to organize this process, which doctor performs the
       coordinating functions, what is the composition of interdisciplinary groups, what
       functions can be delegated to the nursing staff etc.
   •   There are no commitments from the patient to comply with the doctor’s prescriptions to
       say nothing of incentives and possible penalties (there are no agreements with patients).
   •   There is no mention of telephone and electronic interaction, and remote monitoring.
   •   Interaction with a hospital is reduced to a recommendation: if a district doctor or a
       specialist from the polyclinic cannot help the patient, the latter should be hospitalized.
       Given the limitations of the Russian follow-up system, the following elements from the
international CDMPs can be recommended:
       1) Setting-up chronic patients’ registration system subdividing the patients by
           complexity degree with a view to establishing management of patients requiring
           different volumes of clinical and organizational activities.
       2) Formation of interdisciplinary patient management groups. They should have a
           permanent composition and assume general responsibility for the treatment of a
           certain group of patients. The specialists included in the groups should not simply
           provide advice to the patients but also take part in joint activities of systemic nature,




                                                19
           train and advise their colleagues, assess the program performance, modify the
           clinical recommendations etc.
       3) Appointment of program coordinator. The best option is a general practitioner or
           district physician (pediatrician).
       4) Conclusion of an agreement between chronic patients and healthcare providers.
       5) Promotion of the role of proactive measures: encouraging the patients to visit
           doctors, follow-up control of compliance with the prescriptions, patient’s condition
           monitoring, doctor’s home visits etc.
       6) Establishment of a step-by-step algorithm of polyclinic doctors’ actions immediately
           after the hospitalization of complicated patients, assignment of doctors responsible
           for their after-treatment.
       7) Establishment of contacts with hospitals’ doctors.
       8) Establishment of communication with the relatives of acute patients.
       9) Organization of information-based interaction with patients, including the
           establishment of continuous mobile communication, dialogue via emails, remote
           monitoring of health condition, active measures by doctors based on monitoring
           results, specially fitted polyclinic rooms for remote monitoring, assistance in
           receiving advice and sophisticated diagnostic tests (including provisions for
           transporting groups of patients).
       10) Provisions for the monitoring of the treatment process and results:
       - establishment of target indicators not only for the process but also for the results;
       - monthly evaluation of individual plan progress;
       - periodical evaluation of process and results indicators for the totality of patients.
       For each one of the above elements it is appropriate to study in more detail the
experience related to the implementation of CDMPs. It will allow combining the domestic
achievements with the mechanisms that have proved to be effective abroad.


3.4 Intensification of information exchange between healthcare providers

       The impact of information technologies on healthcare integration in the United States
and other western countries can be traced down along three lines. Firstly, they significantly
contribute to an increase in the level of coordination between separate healthcare providers.
Particularly important are electronic medical records (EMRs), which ensure exchange of
information about the services and patient’s condition. EMRs which are common for certain
health system departments provide a kind of “girdle� for consolidating their interaction and
combining the efforts aimed at achieving the ultimate result. It becomes possible to establish



                                                20
more active contacts between doctors of different specializations to combine separate elements
of treatment. The most important forms of such contacts are common patient management
plans; doctors’ prescriptions not only for hospitalization but also for subsequent management
of the patient; monitoring all stages of healthcare delivery to the patient concerned; planning
patient discharges in a close contact with the primary care setting, rehabilitation department etc.
The use of EMRs helps to reduce the duplication of diagnostic tests because their results are
made known to all the participants of integrated care systems. Outpatient doctors can consult
hospital doctors with a lot of experience in the management of certain patients.
       Secondly, new opportunities emerge for interaction between doctors and patients.
Electronic systems are increasingly used to support doctor’s prescriptions, e.g. for sending
reminders about prescribed procedures and medications, warning about possible complications,
prescribing tests and receiving their results, modifying drug therapy and prescribing drugs.
There are now significantly more opportunities for observing the patient’s condition, including
the monitoring of the impact of nutritional quality and other factors on the disease course. The
effect of information technologies on patients’ training process is quite perceptible – most of
the times as a CDMP element. In addition, patients’ web portals are turning into a powerful tool
for spreading new medical technologies. Communicating with each other, patients obtain
information about the potential of different treatment methods.
       Thirdly, there is a significant growth of IT importance for administrative processes.
Electronic accounting of healthcare volumes provided at different stages, comparison of the
clinical activity process and results of different healthcare providers and different doctors, cost
evaluation at each stage of healthcare delivery – all of it significantly expands the opportunities
for measurements in the health system, thus increasing the cost-effectiveness of managing the
healthcare provider and the integrated system. Based on this, it becomes possible to select the
most cost-effective elements of healthcare, and keep track of the input of each element into the
achievement of the target indicators of performance and cost-effectiveness of the resources.
       An indispensable condition for increasing the effectiveness of information technologies
is a clear idea of the content of integration processes. In western health systems, information
systems are based on general perceptions of patients’ pathways, role of each element in ensuring
treatment continuity, healthcare volume accounting units in conformity with the adopted
scheme of healthcare provider incentives, procedure for measuring activity results etc. In other
words, at first, the healthcare delivery setup comes to fruition, and then the information system
takes shape, not the other way round, as it is often done in the Russian health system. The
authors of the Commonwealth Fund Report warn that information by itself is not a cure-all, it
should be properly used in accordance with the accepted organizational and economic schemes.




                                                21
And the participation of physicians in the development of information systems is particularly
important (McCarhy and Mueller,2009).
       An example of IT use for healthcare delivery integration is provided by large-scale
Kaiser Permanente projects. The first project, KP Health Connect, ensures protected
communication between the physician and patient based on the Internet portal of the integrated
system as well as continuously updated electronic health records. The information system
provides a foundation for the physicians to establish and discuss the diagnosis as well as various
forms of telecommunication between different specialists when managing particularly
complicated cases. The second project, My Health Manager, targets patients and offers the
following functionalities: obtaining information for patients’ self-activity: recommendations on
compliance with doctor’s prescriptions, advice on nutrition and healthy life, confirmation or
updates of medical prescriptions by means of email contacts with the physician etc.;
maintenance of personal health record; arrangements for online booking of appointments;
arrangements for receiving drug prescriptions, including their updates based on the previous
contacts with the physician; receiving online advice from the physician or nursing staff when it
is not necessary to visit them. Thanks to information interaction provided by Kaiser Permanente
the number of visits per patient went down by 26.2% between 1999 and 2007. Approximately
34% of patient/physician contacts are based on remote interaction (Chen et al., 2009).
       All of the above processes are most relevant for the Russian health system. IT-based
management of the health system should be aimed at eliminating fragmentation in healthcare
delivery. It will require not only common information but also common rules for its use: clearly
regulated actions of doctors in regard to patients, especially those with particularly high risks.
All the information about the patient should be centralized by the district doctor who is to be
aware of his/her patients’ hospitalizations, their calls for ambulance, results of communication
with any healthcare provider, including private providers. This information should serve a
signal to initiate a contact with a complicated case – even without his/her direct reference to
the doctor.
       In summary, we recommend:
   •   The patterns of health care organization should be first specified with the following
       development of IT system to serve it – not on the contrary, which is the case in Russia.
   •   IT-based management of the health system should be aimed at eliminating
       fragmentation in service delivery. It will require not only common information but also
       common rules for its use: clearly specified actions of doctors in regard to patients,
       especially those with particularly high risks.
   •   Arrange additional forms of information exchange, including feedback of specialists
       after consultation, provision of information on admissions and ambulance calls to



                                               22
         district physicians, on-line consultations, control of recommendations implementation
         after hospital discharge by polyclinics physicians.
3.5 Development of integrated pathways for healthcare delivery and efficient referral
system

    Integrated systems development projects, including CDMPs, which are being implemented
internationally, use integrated pathways of service delivery as their important component.
These pathways are usually defined as a structured multidisciplinary plan of care, which details
the steps in a course of treatment or care and has timeframes or criteria-based progression
(Kinsman et al, 2010). Their key purpose is ensuring the uniformity and continuity of patient
management at all stages of the medical and technological process. Such procedures aim at
developing rules for patient pathways disease-wise, reducing on this basis variations in patient
referrals, and preventing unnecessary referrals. In the framework of this process, the “dual
referrals� term was introduced meaning differently directed movement of patients – from
primary care physicians to specialized care doctors, and feedback between them
(Somanathan,2018).
         Clinical pathways also exist in Russia but they mainly aim at determining the
requirements for the allocation of resources for healthcare delivery. Given the international
experience, it is important to consolidate the integration component of such procedures with a
focus on ensuring the uniformity and continuity of healthcare delivery. For this purpose it is
vital:
         - to include in the pathways for different diseases the algorithms of interaction between
healthcare services to ensure treatment continuity at various stages of care delivery;
         - to establish target indicators for healthcare delivery process and results at the
rehabilitation and outpatient care institutions after the hospitalization of patients with the most
complicated diseases;

         - to include compliance with such regulations and indicators in the healthcare quality
evaluation system;
         - to expand the scope of reviews conducted by health insurance organizations. The
review should focus on quality of post-hospital care and continuity of treatment at different
healthcare delivery stages. The most adequate tool for this purpose is topical reviews.
                An example of successful use of integrated healthcare delivery procedures is
provided by the experience of the urological care system active in the Voronezh Oblast where
a complete vertical was established to deliver medical care – from the primary care level to the
federal core facility for patients with benign prostatic hyperplasia and prostate cancer. Each
stage of care delivery is closely linked to the previous and next stages by means of clearly



                                                23
defined functions of all medical organizations (including the newly established interterritorial
urological care centers), rules of their interaction, patient pathway procedure, and actual
compliance with the provisions of care delivery pathways. E.g., doctors of the urology
department of the oblast hospital have all the information about patients detected at the primary
care level, patient structure in the interterritorial urological care centers, plans of vertical patient
pathways. They advise doctors from interterritorial centers and polyclinics, and have all the
information about the ultimate treatment results after hospitalization. The major results of the
project over the period of 2009-2015: i) the growth of the new urological cases detected at the
level of primary care and a gradual decline in the frequency of the most complicated and
neglected cases; ii) the optimization of patients flows across the levels of service delivery – the
rise in the utilization at the first levels of service delivery and the decline in the share of tertiary
care; iii) a decrease in unit costs as the result of the changes in the structure of new cases; iv)
increase in the share of the first and second stages of prostate cancer from 57.2 to 71.3%; v)
decrease in prostate cancer mortality during the year after the detection of new cases from 14.6
in 2009 to 7.5% in 2013, while the average for Russia – from 14.0 to 10.3% (Apolikhin et al.,
2018). This model deserves to be further disseminated.


3.6. Development of economic incentives to ensure closer interaction between
healthcare providers
        Western countries have been actively looking for financial methods that motivate
providers to implement the integration. Numerous studies (see, for example, Mechanic, Altman,
2009; Tsiachristas, 2013) have shown that the traditional fee-for-service payment for each
service (consultations, procedures, inpatient days etc.) catalyze the fragmentation of care. E.g.,
in asthma treatment, outpatient and inpatient doctors may separately from each other provide
all the necessary care in case of disease aggravation (getting paid for each service they provide).
But if the patient regularly finds him/herself in a condition requiring hospitalization, such
treatment is clearly insufficient: the episodes are repeated, the costs of their arresting using the
hospital resources grow. An alternative to this approach lies in continuous observation of the
chronic patient taking measures to prevent disease aggravation. Motivation for such actions
only develops when specific methods of payment are used (payment for integration).
        There are three major payment methods for integration. The first one is an extension of
a regular pay-for-performance (P4P) method. It is used together with other payment methods
(FFS, capitation or bundled payment) to reward specific integration activities. Bonuses are
paid to promote management of chronic cases. The most famous example is the Quality and
Outcomes Framework _(QOF) in England. Some countries pay bonuses for better information
exchange between providers, as well as between providers and patients. For example in



                                                  24
Denmark, telephone and email patients’ consultations are encouraged by bonuses to promote
on-going tracking chronic patients health status, proactive managing them, coordinating care
with other providers. This method is useful but can hardly contribute substantially to
integration. There is a documented evidence that QOF in England could not improve continuity
and co-ordination of care (Marchall et al, 2014). Also, there has been some reported concern
that this method can potentially result in the neglect of non-incentivized areas (Maresso, 2013).
       The second method is an disease-based bundled payment. The specification of the
bundle of services differs in the literature. Struijs and Baan (2011) address bundled payment
as the payment for integrated set of services provided by outpatient care teams - GPs and
outpatient specialists under programs of specific chronic disease management. Blantes et al
(2009) see this method as a reimbursement of inpatient care cost - not only the episode of
hospital admission but also “a set period of management of a chronic condition�, including
readmission caused by low quality of inpatient care. Thus this method is used for
reimbursement of outpatient care or both outpatient and inpatient care.
       The third method is a global payment for inter-related providers. This method assumes
financial accountability of providers working in integrated networks. They are responsible for
deviations of actual and expected cost (for example, the cost under capitation scheme). Global
payment is always designed in the way that providers can keep savings and therefore are
incentivized to more integration and more control over overutilization of services. They may
bear risks of overspending as well.
       Global payment schemes differ according to the level of financial risk bearing and the
actors that act as risk bearers – PHC providers, hospitals or the entire network of providers. The
specific type of global payment is a PHC-fundholder scheme (further - fundholding). Under
this scheme PCH, providers become holders of funding for outpatient and inpatient care. They
are paid by all-inclusive capitation method, then act as purchasers of care – commission and
pay to specialists, hospitals and other providers of care that deal with the enrolled population.
Their risk bearing creates incentives for closer links with other providers to avoid
overutilization of costly services. This method has been originated in Russia in late 1980-s and
then was used or piloted in various versions in the UK, Italy, Sweden, Finland, Estonia
(McCarhy and Mueller,2009).
       Bundled payment addresses two tasks. The first one is to encourage the transfer of
inpatient care to outpatient units. With the “through� rate, a hospital is interested in better
preparation of the patient for admission carrying out all the necessary consultations and
diagnostic tests and planning inpatient activities. In this case, it is not only hospital inpatient
departments that “make money� but also hospital outpatient units. It is on their activities aimed
at preparing the patient for hospitalization that the amount of savings on inpatient care depends,



                                                25
and consequently, the net revenue of the integrated system as a whole. The second task consists
in ensuring that hospitals are interested in improving quality of inpatient care (prevention of
disease complications and repeated hospitalizations) and provision of after-treatment of
discharged patients.
         The most widely cited example of the disease-based bundle payment is a Geisinger
Health System (GHS) initiative in the USA, implemented by an integrated delivery network of
physicians and hospitals. This system offers forty specific clinical processes related to
managing patients after coronary artery bypass surgery. The integrated rate includes the cost of
surgery, all necessary tests and post discharge follow-up of patients within 90 days. The cost of
services related to possible complications and readmissions is covered by this rate and not
reimbursed additionally. The rate assumes that GHS will reduce the historic frequency of
complications by half, that is pricing is based on growing requirements to quality of care.
Evaluation of the first eighteen months of the project implementation found a 44 percent
readmissions reduction, shorter average length of stay, and reduced hospital charges. According
to Geisinger executives, the major problem is how to equitably distribute episode payments
across physicians, hospitals and other providers involved in the project (Mechanic and Altman,
2009).
         In Europe, disease-based bundled payments are piloted in various countries, including
the Netherlands, the UK, Denmark. Contrary to the US initiatives, they are implemented mostly
in the sector of outpatient care. For example, in the Netherlands the bundled payment was
established in 2007 for diabetes care. Under the scheme, health insurers are able to purchase a
‘bundle� of services needed to manage chronic diseases through the payment of a single fee to
newly created contracting entities called “care groups� These groups are clinically and
financially responsible for all patients enrolled in the diabetes care program. Evaluation of the
scheme made in 2012 indicated that 25% fewer bundled payment patients utilized specialist
care in comparison to care-as-usual patients (not enrolled with care groups). This contributed
to some savings per patient in the cost of diabetes-specific specialist care, but when non-
diabetes costs are included total specialist costs for bundled payment patients increased more
than the costs for care-as-usual patients Another result of this evaluation is the revealed problem
of uncertainty of cost allocation across programs of patients management and regular set of
services reimbursed through FFS. There are concerns that care groups may be double billing
the insurer for the same services – through traditional FFS and bundled payment. (Liano, 2013).
         This implementation problem, in our view, highlights a broader challenge – the narrow
scope of disease-based bundled payment. The scheme is designed for the specific diseases
management programs and doesn’t create incentives for providers in other clinical areas. There




                                                26
is a potential for providers to skew their activity to the most “rewardable� schemes (Sheiman,
2016).
         The interesting example of the global payment is the Alternative Quality Contract
(AQC) in Massachusetts, USA. Starting from 2009, this contract is negotiated between the
insurance company and groups of providers. It covers the entire continuum of care, including
inpatient, outpatient, rehabilitation and long-term care and prescription drugs. Providers in a
global budget model not only share in savings if spending is below the budget but are also
accountable for deficits if spending exceeds the budget. The AQC groups are eligible for P4P
bonuses up to 10% of their budget with performance measures of outpatient and inpatient care.
Song et al (2011) compares the AQC with control group and demonstrates small savings (1,9%
per quarter), as well as some improvement in quality measures of chronic conditions in adults
and pediatric care. All AQC groups met 2009 budget targets and earned surpluses. The
interviews with physicians and administrators of participating groups indicate that sharing
savings between providers is becoming the instrument to reorganize the delivery of care and
ensure continuity of care. “When 50 percent of your patients are at risk, you don’t stop the care
when patients are discharged. We have a huge amount of outpatient work we do in the offices,
in skilled nursing and rehab facilities� - this is the opinion of the senior administrator the
hospital-physician group participating in the AQC. Also, there are new incentives to encourage
proactive actions of physicians to manage chronic cases.
         In Russia, there is a growing interest in the payment rate aggregation. The recent
Program of state guarantees of free health care for 20192 sets forth the “healthcare payment
based on capitation standard rate at medical institutions with divisions providing medical care
at outpatient, inpatient and daycare centers,� i.e. payment for integrated outpatient-inpatient
care.
         The existing international experience can be used to implement such innovation. We
can suggest the following models:

         1) Introduce P4P for polyclinics to supplement the current capitation payment method
               so that to promote: a) development of chronic disease management activities, b)
               more intensive information exchange between physicians, c) coordination function
               of primary care providers, d) effective after-discharge clinical activities. Develop
               indicators for each integrative activities and the model of bonus payment for
               reaching the targets.
         2) Develop bundled payment rate for inpatient care and medical rehabilitation for the
               specified period of time after hospital admission.

         2
             https://www.garant.ru/products/ipo/prime/doc/56663934/



                                                       27
             3) Re-vitalize fundholding method3 and change its design with the use of global
             budget approach, including:
            -make inpatient-outpatient settings (combined hospitals, for example) a fundholder.
            Global payment based on conflicting interests of PHC providers and hospitals (the
            case of Russian fundholding) should give way to the common incentives to ensure
            savings in the entire network of providers;
            -develop a transparent pattern of savings distribution between providers in the
            networks;
            -establish performance targets for each provider in a network that comply with its
            general objectives;
            -mitigate financial risks through a set of arrangements: a) shared savings payment
            is subject to reaching performance targets, b) sharing risks between providers and
            purchasers of care (health insurers), c) optional involvement of providers in risk
            bearing, d) concurrent risk-adjustment of capitation formula. Without these activities
            bundled payment becomes vulnerable and conflicting (Sheiman, 2016).
       4) Establish a managerial control of services under global payment, including the
            enrolment of patients, a sound referral system, a careful specification of the services
            under global payment, measuring the input of each provider.


        4. Management of the integration process

        To strengthen integration, certain rules governing the actions of separate healthcare
providers are required. Such rules are established by various health system actors. In the U.S.A.,
where there is prevalence of private healthcare providers, the role of integrator is played by
some of the major medical institutions and insurance companies. For instance, in order to
establish the integrated system of Advocate Physician Partners in Northern Illinois, which
comprises 9 hospitals and 3,200 independent medical practices, the following most important
practical steps were implemented (Rice, 2011):
                 1)       Selection of system participants determining the results of activities of
        hospitals and medical practices, and identifying the willingness to comply with the
        common rules and coordinate their efforts;
                 2)       Creation of an infrastructure to coordinate healthcare providers and
        ensure prompt contacts with patients using a common information system,
        establishment of a doctors’ web portal, creation of a registry of disease cases and risk


        3
         In 2011 fundholding scheme was used in 10 of 83 regions of the country. However, currently it has been
stopped without any official justifications.



                                                      28
       groups, development of electronic health records and other means of information
       exchange;
               3)     Creation of a system shared by all participants to control healthcare
       quality including, but not limited to, two vital elements: a) development of individual
       doctor records creating opportunities for measuring and comparing their activities; b)
       arrangements for a joint discussion of treatment results involving the physicians from
       all the levels of healthcare delivery. The issues to discuss: At what stage the patient was
       lost? What needs to be done to ensure more effective after-treatment of the patient?
       What is the role of primary care and hospital doctors? Such issues are not discussed for
       the purpose of finding the guilty party but rather for fine-tuning the mechanisms for
       improving the coordination of actions by various healthcare providers;
               4)     Creation of a financial unit to encourage and fine-tune new healthcare
       payment methods aimed at the ultimate result of integrated system operation rather than
       the growth of revenues for some providers;
               5)     Creation of a system shared by all healthcare providers to measure
       performance and reporting results.
       In Europe, it is the government that in most cases undertakes to regulate the integration.
E.g., in Germany, integration is initiated by the federal government. The Federal Social Security
Code (SGBV), the main regulatory instrument on social policy, in 2003 provided for several
types of programs aimed at “opening the borders between separate healthcare sectors� including
chronic disease management programs, integrated care programs for other diseases,
development of specialized outpatient care at hospitals (not provided earlier), integration of
health and social care, and intersectoral approach to complicated disease management. The
document contains framework integration programs, establishes financial conditions for the
participation of sick funds (insurers) in the implementation of various integration programs
(Klusen, 2011).
       In the Netherlands, integration initiatives and relevant regulations are adopted at the
local level – it is for the most part particular chronic disease management programs (Struijs,
Baan C., 2011). In Sweden, it is the law that determines the procedure to ensure treatment
continuity: the municipal authorities are obliged provide for after-treatment of complicated
patients at specialized after-treatment institutions under social service supervision. This
requirement is extremely concrete: after-treatment should be provided within 5 days of hospital
discharge, otherwise the municipality is obliged to reimburse from its own budget the hospital
after-treatment cost (Saltman and Vrngbeck, 2009).




                                               29
        To overcome fragmentation in the Russian health system, the federal regulation for
ensuring an integrated patient-centered approach to healthcare delivery needs to be
strengthened in the following directions:
        1. Initiate programs of chronic and multiple disease management in outpatient settings.
        2. Set requirements to the use of above stated integrative activities.
        3. Develop provider payment methods to promote integration.
        4. Organize monitoring of integration/fragmentation in regional health systems.



Conclusions

People-centered integrated health care initiatives are gaining traction globally as the central
parts of health care delivery reforms. The problem of health service fragmentation has given
rise to innovative organizational, economic and managerial tools to intensify integration
processes in foreign health care systems. Each of them is implemented in the national system
context. The clinical outcomes of these activities are usually positive, while their impact on cost
of care remains unclear – partly because most of these activities are at the initial stage, therefore
require substantial inputs and limited savings.
        The major lines of actions in the Russian health system are: development of the forms
of vertical and horizontal interaction between health providers, development of integrated
models for managing patients with chronic and multiple diseases, intensification of information
exchange between providers, development of integrated pathways for service delivery,
development of economic incentives though new provider payment methods.
        To ensure their use in the practice of the Russian health care system, it is necessary to
adapt them to the established model of healthcare delivery, and the existing financial
mechanisms. To strengthen the integration, it is important to enhance the role of government
regulation of the process with the focus on setting requirements to the specific integrative
activities.



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