Building the integrated system of urological services: The impact on utilization and cost of care

Abstract

Integrated pathways are commonly seen as the way to strengthen service delivery in many countries. Russia has traditionally had a multilevel system of care that consists of facilities varying in terms of the complexity of cases treated. The attempts are currently made to strengthen this system with an emphasis on closer interaction between individual providers. The recent innovation is to establish a new intermediate level of inter-district specialty centers that serve the population of a few local areas and provide additional services. The early detection of new cases and their follow-up management have been activated as a part of a new model. It is piloted in a Russian region with the focus on the cases of benign prostate hyperplasia. The objective of the paper is to present the new model and to evaluate its first impact on urological service performance. The major findings include: 1) the growth of the new urological cases detected at the level of primary care and a gradual decline in the frequency of the most complicated and neglected cases; 2) the optimization of patients flows across the levels of service delivery – the rise in the utilization at the first levels of service delivery and the decline in the share of tertiary care; 3) the need for additional funding to treat the increased number of cases, with the first signs of slowing down this process; 4) a decrease in unit costs as the result of the changes in the structure of new cases, shifts in the utilization of care by the levels of service delivery. These trends are discussed with the focus on the identification of strengths and weaknesses of the new model, as well as the ways to ensure its sustainability.The major lesson learnt is that building a multilevel system of service delivery can be seen as the instrument of integration of care and efficiency savings for a country with limited financial resources for health. This process should go parallel with more profound changes in the health system, of which the most important is strengthening primary care, particularly coordination function of general practitioners.

<p>Concentration of health care providers: does it contribute to integration of service delivery?</p>

“…The major integrative activities are the following: closer cooperation of DPs with urologists in the early detection of new cases; rationalization of patients movement in the system through establishing a new layer of service delivery – inter district urology centers; development and implementation of integrated clinical recommendations and pathways; monitoring utilization, quality and cost of care across the integrated network of providers. This innovative model has contributed to a decline in the need for tertiary urological care; a decrease in unit costs of urological cases; as well as a sharp decline in prostate cancer mortality 6…”

“…The close interaction of providers, however, has ceased to be the objective of health authorities and health insurers as payers. In addition, primary health care has substantially weakened, with a resulting fragmentation of care 3,6…”

“…Most of these countries face serious underfunding of health care and are looking for new instruments to strengthen health systems. Concentration of health providers in these countries is increasingly seen as a way to consolidate resources to achieve better access to care, and to bring together a fragmented service delivery 3,6. However, the interrelationship between concentration and integration is equally unclear for these countries.…”