Concentration of health care providers: does it contribute to integration of service delivery?

Abstract

Background: The concentration of health care providers is a growing process in many countries, including Russia. There is a general expectation that larger medical entities can better promote the process of service integration.

Purpose: This paper explores the impact of health provider concentration on service delivery integration through the indicators of teamwork, coordination and continuity of care in outpatient and inpatient medical facilities. These developments in Russia are compared with international experience.

Methods: National and international literature on health services concentration and integration is reviewed; statistical analysis is based on Russian national data, WHO and OECD databases; a sociological survey of Russian physicians and interviews with managers of medical facilities are used to evaluate the value of integration.

Results: The review of international trends indicates a growing process of mergers to form large hospital and physician-hospital systems, particularly in the USA. Enhanced clinical and administrative integration is usually seen as the logical outcome of concentration. However, growing international empirical estimates demonstrate a controversial impact of concentration on quality of medical care, unit cost (per patient) and integration of care. In Russia, the establishment of consolidated health systems is coupled with an increase in the average size of hospitals, while the number of free-standing providers has substantially decreased. The effect of concentration in the country is also controversial. There is some evidence of its positive impact on restructuring service delivery and the accessibility to some services, but the surveys of physicians don't demonstrate improvement in the organization of service delivery, nor closer links between providers. Surveys of providers don't provide evidence of teamwork, coordination and continuity of care in consolidated settings.

Conclusion: There are many deeply rooted barriers to integration in Russia, of which the most important is the lack of clear objectives of providers mergers. The major lesson learnt is that in the country with limited financial resources, decisions on provider concentration should be carefully justified with the focus on the specific integrative activities. National health policy for integration should be a major pre-condition for the positive impact of concentration on integration.

Keywords: Russian health care; concentration of health providers; continuity of care; coordination of care; integration of service delivery; teamwork.

Figure 1

Trends in the capacity of hospitals in Russia and selected Western countries in 2000–2014 (the number of beds per hospital). Note: Data from OECD and Federal statistical service of the Russian Federation.,

Figure 2

Physician survey question: how often do polyclinic physicians discuss their pre-admission activities with hospital physicians? (% of polyclinic physicians working in hospital-polyclinic entities and independent entities).

Figure 3

Physician survey question: how often do hospital physicians consult polyclinic physicians on the tactics of patients management after hospital discharge? (% of all physicians working in hospital-polyclinic entities and independent entities).

Figure 4

Physician survey question: what is your evaluation of the level of interaction between hospitals and polyclinics (% of all physicians working in hospital-polyclinic entities and independent entities).