Question

what difference does this fragmentation make to patients?
provide a clear example of how to US system is fragmented.
Analyze the potential impact of this fragmentation on actual patient care

Answer 1

Fragmentation in healthcare delivery means the systematic misalignment of incentives or lack of coordination that spawns inefficient allocation of resources or harm to patients. It adversely impacts quality, costs and outcomes.Eliminating waste from unnecessary, unsafe care is crucial for improving quality and reducing costs-and making the system financially sustainable. Many believe this can be achieved through greater integration of healthcare delivery. It is also accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them. Evidence suggests that IDSs can improve healthcare quality, improve outcomes, and reduce costs-especially for patients with complex needs-if properly implemented and coordinated. No single approach or public policy will fix the fragmented healthcare system.

• It is no secret: our healthcare system is fragmented, suffering from what George Halvorson calls "clinical linkage deficiencies."
• These systemic deficiencies, evidenced by conflicting incentives and lack of coordination, cost lives and fuel the unsustainable spiral of US healthcare expenditures.

For example, the Dartmouth Institute for Health Policy & Clinical Practice estimated that 30% to 40% of all hospitalizations are avoidable and that among regions, Medicare costs can vary 2- or 3-fold higher to treat similarly ill patients, without better outcomes.

• As late as 2005, preventable medical errors caused more deaths than breast cancer, automobile accidents, or drowning.
• In January 2009, an article in The New England Journal of Medicine stated that using a simple surgical checklist could reduce the death rate from surgery by half, decrease complications by more than a third, and save US hospitals about $15 billion per year.

Potential impact of this fragmentation on actual patient care

Fragmentation is steeped in the history and culture of medicine and is embedded population-wide in the current system-operationally, financially, and in the clinic. Organized medicine uses the term "free choice" fee-for-service (FFS), specifically, individuals should have freedom to choose physicians and hospitals anytime a la carte. They should not be allowed to choose an insurance plan that limits their choice of provider to those in an organized delivery system in exchange for what they judge to be superior value.

• The professional culture of medicine has contributed to fragmentation by revering physician autonomy and infallibility.
• Education and training emphasize individual rather than team performance; physicians tend to practice as individuals.
• Predictably, solo or small single-specialty group practices have dominated the landscape, with unfortunate fallout.
• Wide variation in practices and costs and relatively low accountability-a dearth of guidelines, utilization and quality management, collaboration, and peer review.
• Traditional guild-like control, coupled with insulation from accountability, has given physicians a de facto monopoly over major decisions, including admitting patients to the hospital and choosing interventions.
• As a result, physicians still control (directly or indirectly) most of personal health spending,not withstanding extensive insurer-imposed limitations.
• The accelerating advances and complexity of modern healthcare have driven greater specialization and a "silo approach" to healthcare consistent with the described isolationist history and professional culture.
• Yet, in recent years, increasingly prevalent chronic, often comorbid conditions (eg, diabetes, heart failure, depression) require that patients receive care from multiple providers in multiple settings.
• Although intensified specialization sought to generate greater interdependence among clinicians and the need for cross-silo coordination, greater specialization has exacerbated fragmentation by increasing the number of narrowly trained specialists.
• Other observers assert that organized medicine has historically used its considerable clout to preserve the status quo, resisting efforts to systemically improve the quality and safety of medical care and to form multispecialty group practices (MSGPs) or prepaid group practices (PGPs).
• Throughout this evolution, FFS has been the primary payment model.
• However, the FFS model contributes to fragmentation. Under FFS, physicians earn more by providing more services, thereby interposing an inherent disconnect between physicians' economic self-interest and the interests of their patients.
• In short, traditional FFS rewards production volume rather than value or outcomes.
• For patients, who simply want their doctors to help them stay healthy or get better, the fragmented system resembles.