Vertical integration in a changing landscape
Integrating a large public psychiatric unit with private primary care units
A large-scale reform of health care and social services is taking place in Finland. The responsibility for providing services is taken from municipalities and given to larger districts. Publicly funded healthcare is going to be opened to private sector competition. The details of the reform are not known yet, so both public and private sector are preparing themselves somewhat frantically to the unknown future. For mental health sector the reform could enable services through larger units and better coordination than before. Small local mental health units that we have nowadays are vulnerable, tend to isolate themselves from the outer world and have a narrow repertory of treatments.
Helsinki University Hospital Department of Psychiatry is a large public unit that provides both tertiary and secondary health care services to population of about 1,1 million through service lines (=main patient groups like Mood disorders or Psychoses). We are looking for possibilities to both horizontal and vertical integration. We have already some experience of well integrated service chains for mental disorders, where patients get our online therapies and brief therapies while under responsibility of family doctors of primary health care. This has been relatively easy between stable public organizations, but things are going to be more complicated due to the ongoing reform. Secondary health care in psychiatry will probably stay mainly public, but the primary health care will probably be a rapidly changing landscape, and fairly difficult to integrate with.
So the question would be how could our large psychiatric unit vertically integrate with numerous and changing private primary health care units?
Psychiatric services in the US are mostly a mess. Underfunded and irregularly spread out. Most physicians that I know are appreciative of the support of psychiatry services and would welcome help from a more specialized unit. Perhaps developing care protocols in conjunction with the primary health care units to provide clarity as to what services they should offer, and when it is more appropriate to refer. That works with some other specialities, I’m not sure if it is as applicable to Psychiatry.
This sounds like a risky experiment into area’s ‘where no man has gone before’. ‘Large scale’; that is thrilling.
I have two remarks.
Given the experimental status and the large number of management uncertainties, I would make the problem as small/tangible as possible. And then take it one step at a time. Limit yourself to look for solutions for only a well defined ‘service line’, which is probably interesting for profit organisations and which is relatively high protocolized. (it seems to me that a profit organisation will only engage itself with more protocolized treatment programs, thus reducing (financial) risk) And than start to discuss the different (vertical) roles in the treatment of these clients. My point is; make the subject well defined and design processes about who does what in which situation. Stay away from discussions about abstract ‘concepts’. Maybe (not to severe) alcohol or drug abuse would be a workable first service line.
My second remark is that I am a little sceptic about a vertically integrated profit/non-profit complementary treatmant program, because the profit-organisations always will define their part of the treatment process in such a way that they will take care of the profitable part of the treatment and leave the non profit with ‘the bleeders’. So you have to get the health unsurers involved, to avoid a situation where you are being left with the role of ‘carbage can’, as teaching hospitals tend to do.
We are also in the midst of “vertical integration” of our mental health services with the herculean task of engaging a very heterogenous primary care and volunteer welfare organisations (VWOs). Whilst things are in a state of flux and it is tempting to wait for things to settle down, I would suggest that a dynamic state of flux is the natural state of any healthcare organisation.
I would suggest a multi-prong approach to laydown some groundwork. We have looked into upskilling our primary care physicians and VWOs via training programs as well as a support network. Structurely, as things are being re-organised, we have to advocate that there should be no financial gradient for the patient between seeing a hospital and private primary care provider. Similarly, the provision of medications and services should not be that different.
We have assigned teams to geographical regions to build up relationships with the community partners, adopting a 70/30 approach.
This groundwork hopefully will allow us to adapt to systemic changes in the future.