Fragmentation of the US Health Care System

America's unsustainable growth of health care expenditures is inextricably linked to the country's economy. With estimates of health care spending projected to reach $5.0 trillion or 20% of the GDP by 2021,1 health care spending may well be the anchor that brings the economic ship to a grinding halt.

Large discrepancies become apparent when spending levels on a per capita basis and outcomes are compared between the United States and other developed countries.2,3 These data not only shed light on the differences but also provide an opportunity to consider those factors behind higher costs and lower-quality scores. The structure and processes of care in the United States hold clues to the relative lack of efficiency and effectiveness of the US health care system.

Since the advent of private health insurance in the early part of the 20th century, the means by which health services are paid in the United States promoted the development of a highly fragmented, illness-focused delivery system. Until only very recently, payment models that encourage collaboration, healthy behaviors, a focus on total cost of care, chronic disease management, and outcomes were largely nonexistent in the mainstream of the US health care system.

The impact of the fee-for-service (FFS) payment model as a significant contributor behind the escalating cost of health care could be observed during the Great Recession (2007-2009). Martin and colleagues4 reported that the recent decline in the average rate of growth in national health care costs was attributed to reductions in use and intensity of health care services.

The prevalence of the FFS payment model contributed to the evolution of a care delivery system that functions in discreet silos. Investment in costly technology centered within hospital-based specialty services, promoting overuse of supply-sensitive care. Reimbursement based on processes of care (FFS) rather than episodes of care provides little incentive to coordinate care among disparate providers.

The costs associated with the overall lack of care coordination, or discontinuity of care, in the United States are estimated to be in the range from $158 million to $226 million. Medical errors, duplication of services, overtreatment or underuse of effective care, and compliance with treatment plans have been linked to inadequate or absent coordination of care.5-8

Healthy People 20-Something

September 2014 marked the 24th anniversary of the introduction of Healthy People 2000 goals by the Centers for Disease Control and Prevention. These national health promotion and disease prevention objectives held promise to serve as a national strategy to align predominately state and local jurisdictions around improving the health of the populations in those areas.

Subsequent iterations occurred, yet the desired goals of increasing the quality and years of healthy life and reducing health disparities remained the guiding lights. Progress toward these objectives has been slow, particularly in the areas of nutrition, weight status, and physical activity. The intent was for government and nongovernment organizations to work collaboratively toward improving the health of Americans at grassroots levels.

Barriers contributing to the slow pace of improvement overall relate, again, to fragmentation. This time not within the health care delivery system but arising from the chasm that exists between the public health sector and the health care delivery system in the United States. This separation can be traced to funding sources and a fundamentally different view of perceived missions (illness vs health).9

A new delivery model is needed that integrates what Zismer9 suggests are the complementary disciplines found in public health practice models and the current model of health care delivery. If you thought that crossing the quality chasm has been challenging, only an act of Congress can change the direction of health care delivery.

Implementation of the Affordable Care Act

Enter the Affordable Care Act (ACA). Passed in 2010, the ACA set out a series of payment reforms designed to curb the cost of health care, reducing the financial burden on the federal government in the short term and creating a fiscally sustainable health care system in the long term.10 Many of these measures also would improve coverage levels reducing, but not eliminating, the numbers of uninsured in the United States. Taken in totality, the impact of improving coverage levels, whether through Medicaid expansion, elimination of disqualifying conditions, making insurance affordable through health exchanges, or mandating individual coverage, would be to reduce financial barriers preventing access to health care. In the short run, however, expenses are expected to increase, not decrease.

Other provisions of the ACA impact costs by making the organization and delivery of care more efficient and effective over the long term. Shared savings, bundled payments, and chronic disease management and medical home demonstration projects fundamentally change the organization and delivery of health care.

Common Vision: Triple Aim

Perhaps, no other aspect of the ACA is more important than the inclusion of the 3 elements of the IHI's Triple Aim. This elegantly simple model has, perhaps, the first time in the history of the health care delivery system in the United States created a common, unifying vision in the industry. The Healthy People 2000 objectives could have been that vision; however, a crucial step was left out when these objectives were introduced and that step is linking payments and penalties to performance.

In addition to the Triple Aim, the ACA promoted testing payment models that break away from traditional FFS in favor of models that encourage and reward collaboration, that encourage risk sharing, and that will by necessity require integration of historically separate components of the public health and health care delivery sectors. Managing the organization and delivery of these evolving health care delivery models will require what Marcus and Dorn11 of the National Preparedness Leadership Initiative define as meta-leaders to lead not only within silos but also create and lead connectivity among these disparate stakeholders.

Integrating Systems of Care Along the Public Health Continuum

Presented in this section are 3 examples of how the ACA is changing the organizational landscape and models for delivering care from the fragmented "one patient at a time" model to an integrated community population health management approach. From integrating community health workers, to expanding outreach, and to building the foundation for health system transformation through patient-centered medical homes, the impact from the ACA is becoming increasingly visible across the country. Public health practice is merging with traditional health services delivery in collaborative efforts to improve care coordination, reduce costs, and improve patients' and families' experience of care.

Integrating Community Health Workers

Islam and colleagues12 present and discuss different strategies for integrating community health worker models through facilitated enrollment strategies, patient-centered medical homes, coordination and expansion of health information technology efforts, and new payment options.

Targeting outreach efforts

Dybdal and colleagues13 share their strategy and findings in "Putting Out the Welcome Mat: Targeting Outreach Efforts Under the Affordable Care Act" for targeting outreach to individuals eligible for Medicaid coverage or subsidies under the ACA designed to improve access for vulnerable populations in Minnesota.

Building primary care homes

Rissi and colleagues14 provide insights drawn from their evaluation of the implementation of Oregon's Patient-Centered Primary Care Home program and the adoption of the model by primary care providers.

Toward value

Significant short- and long-term challenges remain with regard to improving the value Americans receive for the dollars spent on health care. Health care costs are in many ways the result of poor health. The need for new organizational and delivery models is essential to actually improving health. These selected examples highlight the need to further integrate public health practice competencies into the traditional model of health system management. Specifically discussed in these proceedings are population health evaluation, total cost of care management, social engagement, and building integrated, interprofessional team models of care management.9 The complexities of the ACA are in many ways reflective of the complexities of the health care system in the United States. As demonstrated by the authors in this section, the ACA has the potential to improve the efficiency and quality of the health care delivery system by promoting the integration of public health practice into the management of health services.

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