Background and objectives
One concern arising from the market developments introduced in long-term care is that competition may have contributed to a further fragmentation of care provision. As a consequence, users, many of which are in a vulnerable situation now have to navigate an even more complex system of providers to address their needs of health and social care. This study therefore set out to investigate on the question how increasingly fragmented provider markets that underline choice and competition are compatible with efforts to integrate health and long-term care and to improve outcomes for users.
The study focused on older people with needs for health care (e.g. acute, primary care) and long-term care (e.g. home care, residential care). It explored to what extent integrated care has been achieved in a context of market-oriented governance promoting competition and user choice, and how different stakeholders are coping with related challenges.
For this purpose, a comparative research approach was chosen to analyse differences within and between countries, namely in selected municipalities in Sweden (Norrtälje) and Germany (Dortmund and Leipzig). Germany was chosen as a comparator for Sweden because it represents arguably the most market-oriented governance of long-term care system in Europe, a highly diverse provider market due to relative low barriers to entry, and a high level of user choice based on a mix of benefits in cash and in kind.
Fieldwork for this project (semi-structured expert interviews) took place between October 2014 and March 2015. The final report (August 2015) provides, first, an overview of theoretical considerations concerning the compatibility of choice and competition with integrated care as well as definitions of key concepts. Following the presentation of general framework conditions of health and long-term care systems in Sweden and Germany, and the presentation of the selected sites of case studies, the most important findings from expert-interviews are conferred in a comparative perspective. Finally, the discussion of findings leads to general conclusions and potential opportunities for mutual learning.
The findings of this qualitative study showed a nuanced picture as to the potential conciliation of choice and competition, and integrated care. The overall opinion of those interviewed in the three sites was that it was possible to achieve integrated care in a context of user choice and competition. For many of the different stakeholders interviewed – particularly in Germany – user choice had been internalised as a de facto right of users. Integrated care initiatives in the German sites are thus forced to work in a context of choice and competition, in some cases they even were a reaction to this basic framework condition, while in the Swedish site, competition became a new challenge for an already established integrated care model.
Apart from the well-known barriers to cooperation (lack of information, time, incentives, and trust), a number of coping strategies could be identified that actually enhance collaboration, e.g. to draw on other providers to supplement one’s own services or to channel users to partners in the network that would be more suitable to deal with particular needs. This process of ‘enlightenment’ towards voluntary cooperation seems still to be an on-going process in Germany, while in Norrtälje new providers that appeared in the context of the newly introduced customer choice model complemented the already existing integrated care model in 2008 have to work within predefined integrated structures and processes. Both in Swedish and German sites there is, however, fierce competition for appropriate staff, and it seems that this type of competition is often more detrimental to cooperation than competition for clients, in particular under conditions of undersupply.
Lessons learned and policy recommendations
While direct comparisons between the three sites should be considered with caution, given the underlying governance differences between the German and Swedish health and long-term care systems as well as the differences in size as well as the degree of integration between the three study sites, there are however a number of salient lessons and recommendations arising from this study that are liable to be applicable to other contexts.
- There are different ways to overcome barriers: The three study sites showed that it is possible to build common values and to enhance trust and joint working through quite dissimilar approaches to integrated care. There is no ‘one-size-fits-all’ solution, but it is necessary to leave enough time and space to stakeholders to find common grounds. This means that short-term projects of integrated care can hardly be successful, though competition and customer choice may accelerate the search for solutions.
- Pooling resources is as salient as difficult to accomplish: The ability to allocate resources according to needs rather than to institutional settings and budget lines (e.g. health vs. long-term care) is extremely important for integrated care. Governance structures should be shaped to provide opportunities for pooling resources.
- The importance of transparency and a level-playing field: Creating trust among otherwise competing providers calls for transparent procedures in the allocation of users and funding (price-setting) and in quality assurance. Potential conflicts of interest should therefore be avoided as well as opportunities for ‘cherry-picking’ or free-riding.
- Organisational design plays a major role in creating collaborative structures: It is helpful to create time and space for exchange and cooperation. In the context of LTC for older people it is also necessary to define integrated care in a broad perspective, as shown by the case study sites, rather than to restrict it to managed care for selected diseases. For any attempt to improve collaboration in LTC, in particular at district or neighbourhood level, features identified in the three sites such as co-management for ‘Senior Citizens Centres’, shared offices and ‘Round Tables’ are useful tools to facilitate transparency, mutual understanding and problem-solving. Furthermore, integrating care by means of discharge management in combination with intense care planning involving users, their family and other key-stakeholders, and the combination of home care, basic home nursing and rehabilitation at home, as for instance in Norrtälje, is seminal.
- Competition seems compatible with integrated care: User choice and competition can be drivers for integrated care, even in very competitive environments, as the German experiences show. However, it should be underlined that additional efforts are needed to prevent market-failure that would occur under conditions of an unregulated market. The Swedish case study revealed a much more regulated approach to competition, with an already established integrated care model and an appropriately funded lead-agency in the driver’s seat.
- Empowering users to reconcile user choice and integrated care: Although most stakeholders were in favour of user choice, this issue remained arguably more contentious. The more integrated care models are the more they may put into question user choice and empowerment – particularly if based on a more medicalised, disease-focused model. In any case, putting in place appropriate, empowering support mechanisms and means to convey information for user choice remains a general challenge in LTC. In competitive environments, it is useful to look for independent, professional and low-threshold solutions that promote transparency. Well-trained professionals are therefore needed to balance individual clients’ preferences and given supply structures.
- Moving from fee-for-service to value-based provision: It will be necessary to focus further research efforts on the issues addressed in this study, a major caveat of which is undoubtedly that differences as to the outcomes for users could not be assessed and compared. Apart from major methodological problems inherent to such measurements of quality of care or quality of life, even within single regions or countries, further efforts to promote integrated care delivery will entail thinking about new types of incentive structures for integrating care.
This study has shown that current ways of funding in ‘silos’ based on fee-for-service payments remain an important barrier for collaboration. As all providers are chiefly driven by chasing for clients or service hours within a taylorised system of professionally divided tasks, general aims such as social and individual well-being often get out of sight. Under conditions of market-oriented governance the challenge is therefore to find new ways to use those aspects of positive dynamics of competition that have been identified in this study to enhance vertical and horizontal collaboration in long-term care by means of appropriate financial and professional incentives.