	Scope and Methodology

To address our research objectives, we selected a judgmental sample of   15 IDSs that clinically integrate primary, specialty, and acute care and  serve uninsured and medically underserved populations. The 15 IDSs vary in many aspects, including the degree to which they are  integrated, specific organizational features, and payer mix (e.g., extent to  which they serve Medicare and Medicaid beneficiaries and the uninsured)  (see app. We administered a structured interview protocol  with chief medical officers (or other system officials, as appropriate) to  obtain information on organizational features that IDSs use to support  strategies to improve patient care; approaches IDSs use to facilitate access  to care for underserved populations; and challenges IDSs encounter in  providing care, including care provided to underserved populations. IDSs Reported That Using Electronic Health Records, Operating Health Insurance Plans, and Employing Physicians Support Strategies to Improve Patient Care

The 15 IDSs in our sample collectively reported that organizational  features such as using electronic health records (EHR), operating health  insurance plans, and employing physicians all support various strategies  for improving patient care, including care coordination, disease  management, and use of care protocols. Operating a Health Insurance Plan Was Reported to Support Patient Care Strategies by Providing Resources and Increasing the Availability of Data on Patients in the Plan

Officials from IDSs in our sample reported that operating a health  insurance plan can support patient care strategies by providing to the IDS  both financial resources, such as savings resulting from reducing  avoidable hospitalizations for health plan members, and data on health  insurance plan members. IDS officials reported that financial resources  could be used to fund services such as care coordination—which many  insurers do not reimburse—and the data could be used as a basis for  implementing strategies such as disease management. Accountability for Quality of Care

Employment of physicians was reported to facilitate physician  accountability for quality of care because physicians who are employed by  the IDS are expected to meet certain performance indicators, and the IDSs  collect data on and review physician performance. Mitigation of Physician Concerns Related to Payment

Officials from several IDSs told us that employment of physicians can  facilitate provision of care to underserved populations because  compensation from IDSs can mitigate physicians’ concerns that they may  not receive payment from uninsured patients. IDSs Use Community- Based Settings and Other Approaches to Facilitate Access to Care for Underserved Populations

The IDSs in our sample discussed several approaches that they use to  facilitate access to care for underserved populations. These include  providing community-based care, conducting outreach, helping patients  apply for coverage programs, providing financial assistance, integrating  mental health and primary care services, and collaborating with  community organizations. Some IDSs, such as  Denver Health and Parkland, operate FQHCs within their systems. At two other IDSs—Seton and Henry Ford—there  are no FQHCs among the clinics in their system, but both IDSs collaborate  with local FQHCs that are not part of their system. Integrating Mental Health and Primary Care Services

To improve access to mental health care services for patients, including  for underserved populations, some IDSs integrate mental health and  primary care services by providing mental health screenings in primary  care locations or collocating mental health providers in primary care  settings. IDSs May Face Various Operational Challenges in Providing Care

IDSs in our sample reported facing various operational challenges in  providing care, including care for underserved populations. Some reported  that not receiving reimbursement from health care insurance companies  for the care coordination services they provide to patients is a financial  challenge. Other operational challenges IDSs reported included finding  specialty care for underserved patients, including mental health care;  sharing information with providers outside the system; and changing  management and physician cultures to adapt to organizational change.
Why GAO Did This Study

Health care delivery in the United States often lacks coordination and communication across providers and settings. This fragmentation can lead to poor quality of care, medical errors, and higher costs. Providers have formed integrated delivery systems (IDS) to improve efficiency, quality, and access. The Health Care Safety Net Act of 2008 directed GAO to report on IDSs that serve underserved populations--those that are uninsured or medically underserved (i.e., facing economic, geographic, cultural, or linguistic barriers to care, including Medicaid enrollees and rural populations). In October 2009, GAO provided an oral briefing. In this follow-on report, GAO describes (1) organizational features IDSs use to support strategies to improve care; (2) approaches IDSs use to facilitate access for underserved populations; and (3) challenges IDSs encounter in providing care, including to underserved populations. GAO selected a judgmental sample of 15 private and public IDSs that are clinically integrated across primary, specialty, and acute care; they vary in their degree of integration, specific organizational features, and payer mix (e.g., extent to which they serve Medicare and Medicaid beneficiaries and the uninsured). GAO interviewed chief medical officers or other system officials at all 15 IDSs and conducted site visits at 4 IDSs, interviewing system executives and clinical staff.

What GAO Found

IDSs in GAO's sample reported that using electronic health records (EHR), operating health insurance plans, and employing physicians all support strategies to improve patient care. An EHR contains patient and care information, such as progress notes and medications. Some IDSs said that using EHRs supports their patient care strategies such as care coordination, disease management, and use of care protocols by increasing the availability of individual patient and patient population data and by improving communication among providers. IDSs also reported that operating a health insurance plan can support patient care strategies by providing to the IDS both financial resources, such as savings from reducing avoidable hospitalizations for health insurance plan members, and data on plan members. For example, financial resources could be used to fund services such as care coordination--which many insurers do not reimburse--and the data could assist with strategies such as disease management. Employment of physicians was reported to facilitate physician accountability for quality of care because physicians who are employed by the IDS must meet certain performance indicators, and the IDSs collect data on and review physician performance. Employment of physicians was also reported to increase adherence to care protocols and to facilitate provision of care to underserved populations through compensation that mitigates physicians' concerns that they might not receive payment from uninsured patients. IDSs in the sample discussed several approaches they use to facilitate access to care for underserved populations. These approaches include using community-based settings, such as school-based health centers and federally qualified health centers (FQHC); conducting outreach; helping patients apply for coverage programs such as Medicaid; providing financial assistance; and collaborating with community organizations, including faith-based organizations. For example, some IDSs operate FQHCs within their system, and others collaborate with local FQHCs that are not part of their system. In addition, to improve access to mental health care services for patients, including those in underserved populations, some IDSs integrate mental health and primary care services. IDSs in the sample reported facing various operational challenges in providing care, including care for underserved populations. Some reported that not receiving reimbursement from health care insurance companies for the care coordination services they provide to patients is a financial challenge. Other operational challenges IDSs identified included finding specialty care for underserved patients, including mental health care; sharing clinical information in patients' EHRs with providers outside the system; and changing management and physician cultures to adapt to organizational change. The Department of Health and Human Services reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate.