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Price, Quality, and Barriers to Integration

Recent conferences on integrated systems and current analyses of healthcare markets suggest-as Douglas Conrad and Stephen Shortell appear to acknowledge-that the debate regarding real, "virtual," or less-than-virtual integration in healthcare systems is less a debate about specifically identifiable models than it is one about places along several continuums. In healthcare markets today, hybrids rule. To the extent that one can define a shortterm trend, it is apparent that the present trend is not with more fully integrated systems. In today's marketplace, the greater flexibility of less integrated systems, as well as their ability to take advantage of excess capacity, is proving more valuable than the presumed greater potential of more integrated systems to coordinate care, integrate physicians, and align incentives across operating units and providers. At the risk of oversimplification, it may be asserted that underlying this advantage is a current marketplace preference for lower price over higher quality. Various assessments of more and less integrated systems seem to reveal that individuals who perceive greater value in more highly integrated systems are placing more emphasis on performance, defined primarily as quality. The constructs of physician integration, coordination of care over a continuum of services, clinical integration, expanded use of protocols and clinical guidelines, and population-based healthcare that are often the focus of pro-integration assessments certainly may have value in terms of improving efficiency and lowering price. But their core value, it would seem, has more to do with promoting quality of care for the individual patient and the full population covered. By contrast, most of those who favor-or anticipate the dominance of-less integrated systems seem more focused on price. Their presentations and analysis focus on staying away from costly investments in bricks and mortar, on the need to expand or downsize quickly, and on the greater flexibility inherent in contractual relationships, even long-term ones. There is little in their writings or presentations that would suggest a lack of interest in improving quality, but as one consulting group bluntly concluded, Low Price, High Quality is fine market posture; High Price, High Quality is not. The equation that sets value equal to quality over price (V = Q/P) may help provide insight into today's ascendancy of price. Insofar as it is related to the perception of value in today's marketplace, however, this equation is clearly flawed. It assumes, for one thing, that a 25 percent increase in quality will provide the same increase in value (to most purchasers) as a 25 percent reduction in price. But given employers' increasing aggressiveness about lowering healthcare costs, nothing could be further from the truth. Some of nation's largest and most visible employers are heavily invested in quality improvement. But their visibility and testimony in current intellectual and public debates may conceal more dominant realities; for the vast majority of employer-purchasers, improvements in quality-above, perhaps, a minimum standard-do not lead to a perception of significantly greater value, especially if they are accompanied by a higher price. Moreover, even if employers were more responsive to higher quality, competition for their favor would still be based on the perception of quality versus the actuality of price. Healthcare systems that seek to improve market posture by demonstrating higher quality may find their ability to do so is modest at best. Such realities leave the more highly integrated system-the strongest asset of which may be its greater potential to coordinate care of individual patients and populations through improved clinical and physician integrationfacing even higher barriers than those outlined by Conrad and Shortell. In short, their greatest assets may be undervalued-at least by those doing the bulk of the purchasing. …