In recent years there has been unrest surrounding integrated care. The fee that general practitioners are charged for
The possibility of the health insurer providing integrated care on top of the regular rate is under threat. A discussion on the content is also beginning, because is integrated care, as we use it in the Netherlands, really integrated care? And does the model fit in with current practice, in which we are seeing more and more people with multimorbidity and a complex demand for care?

Not whole-chain care but half-chain care

In chain care(disease management), the various links in the provision of care are attuned to each other in such a way as to create a coherent service, based on the symptoms and needs of the patient. The concept came over from the US in the 80s and 90s and was applied in the Netherlands in primary care for patients with chronic diseases such as type 2 diabetes, cardiovascular problems and COPD. However, the second line was not included in the funding of the chain. As a result, there is in fact no chain care in the Netherlands, but rather half-chain care. Is that bad? Yes, because that is not how we achieve the desired results in terms of quality improvement and cost savings. In the Netherlands, where integrated care is applied, we see rising costs and only a minimal improvement on a number of quality indicators. In contrast, clear positive effects have been demonstrated in countries such as the United States, England and Germany. There is a simple explanation for this: in these countries, health insurers conclude chain contracts with both the primary and secondary care providers that work together in one organisational network. In these organizational networks, they have common quality frameworks and guidelines. So that’s how it works.


Multimorbidity is the new normal

Is it simply a matter of implementing integrated care better and everything will run smoothly? Not quite. Chain care is a linear model that is fine for patients with one chronic condition without other significant problems. However, the current reality in the Netherlands is different. 11% of the population is struggling with multiple chronic diseases and 13,3% has health problems combined with other, complex problems (high need high costs patients). These people are going to get stuck in chain care. They are, as it were, broken down into pieces and, for each disorder, end up in a different chain with an associated treatment protocol. If this is not properly coordinated, these patient groups will fall between the cracks; a highly undesirable situation. The question is: who is going to take care of the coordination, primary care or the hospital? Who will be responsible? We need to have that discussion.


Chains don’t exist, care networks do

Linear models, such as chain care, therefore have their limitations, but in the right way
implemented, they are certainly of value. For example, they give a grip on the costs. However, given the complexity that lies ahead, it is important that we take the next step towards network care in the region. In such a care network, everything is connected and care is provided on the basis of cooperation and partnership. Power is divided between the various organizations involved. Not ‘everyone a boss’, but ‘everyone the boss’ is the adage. Control usually takes place on the basis of a mutually accepted form of direction. This makes it easier to exchange knowledge, products and services. The differences in interests and perspectives between the organizations make the collective stronger. Networked care requires a regional approach; at the local level, we need to look at which populations and which problems we are dealing with and create an organisational network around them. Care in such an organizational network is based not only on medical, but also social, economic, emotional and cognitive factors, and has the important advantage of adapting easily to change. This new way of working does not require any new buildings, it can simply be done digitally. It is a matter of making agreements about how we coordinate care, where we place responsibilities, how we call each other to account and how we measure the results.


This seems revolutionary – and in the Netherlands it is – but abroad the model has been implemented several times with good results. A number of best practices show that for complex patient groups, it works if you organise care across the whole chain of prevention, care and welfare, and make people jointly responsible for the outcomes. This was also shown in a review we recently conducted based on the Rainbow Model for value-driven care. There, too, we found a significant relationship between professional coordination and integration and a decrease in mortality and unwanted hospitalizations.

Looking to the future with a broad view

So is chain care dead? No, but the way we apply it now in the Netherlands, it will not last long. Let’s broaden our view beyond the walls of our organizations, truly taking the needs of the patient as our starting point. The increasing multimorbidity and complexity of care also leave us no other choice. Fortunately, we see that shifts are taking place. Health insurers, medical specialists and GPs are realising that the current situation calls for a new approach, so that we can get and keep the lurking problems under control. The question is
Only: do we dare to embrace this new way of thinking and put it into practice? It does mean that changes must take place at all levels of healthcare. Network care calls for entrepreneurship on the part of local care providers who, together with partners in the region, are willing to run financial risks as to whether or not care results and cost savings are achieved. In addition, contract innovation by health insurers is needed to achieve the necessary efficiency and quality incentives. Policymakers should also give the parties in the field the freedom to organize the optimal form and scale of care that suits the local population and stop simultaneously stimulating competition and cooperation in the field. In short: there is work to be done. But the scientific evidence is there that organising care around care networks produces results and we don’t need to reinvent the wheel! So, what are we waiting for?

Pim Valentijn

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