Correspondence

The Case for Integrated Delivery Systems

N Engl J Med 2010; 362:86January 7, 2010

Article

To the Editor:

In his Perspective article, Crosson (Oct. 1 issue)1 discusses a concept for health care delivery called integrated delivery systems, which is similar to the vertical-integration system proposed by Hillary Clinton. Each system was designed to compete on the basis of location, quality, and pricing.

I was one of the many doctors and administrators who helped to build our physician–hospital organization that eventually grew to include three hospitals and more than 300 doctors. We met with considerable success and were embraced by local employers. Nonetheless, after 10 years of operation, we were shut down. Why did that happen? We followed the mandates that were set by Clinton's new plan. Unfortunately, another arm of our federal government, the Federal Trade Commission, prosecuted our organization, seeing it as illegal for competitors to come together, establish an organization, and then set prices, even if the new price was lower than the historical price. In other words, I wish to offer a cautionary note: Health care institutions and doctors who place themselves ahead of the curve put themselves at considerable risk that a government agency may attack them.

Sanford Dennis Guttler, M.D.
Crown Health Care, Granite Falls, NC
sanfordguttler@mac.com

No potential conflict of interest relevant to this letter was reported.

1 References

1. 1

   Crosson FJ. 21st-Century health care -- the case for integrated delivery systems. N Engl J Med 2009;361:1324-1325
   Full Text | Web of Science | Medline

Author/Editor Response

Guttler raises a very important point about both the intent behind the accountable care organization model and its future viability. The purpose of delivery-system integration and payment reform is to improve quality through care coordination, reduce inappropriate care, and create a sustainable professional environment for physicians and other providers. But two seemingly contradictory changes are needed. There are some antitrust and other federal and state regulations that inhibit some potentially beneficial forms of integration among physicians and between physician groups and hospitals. These regulations need to be carefully amended to be more flexible. On the other hand, a new regulatory or structured-market environment will be needed to mitigate the potential for monopolistic pricing behavior by providers. As I said in my article, “Regulators . . . need to remove certain barriers to integration while ensuring that system development does not lead to abusive pricing.” Striking this balance will not be easy, but it is a small price to pay for a better American health care system.

Francis J. Crosson, M.D.
Kaiser Permanente Institute for Health Policy, Oakland, CA

Since publication of his article, the author reports no further potential conflict of interest.

Citing Articles (4)

Citing Articles

1. 1

   E. Ghedin, J. Laplante, J. DePasse, D. E. Wentworth, R. P. Santos, M. L. Lepow, J. Porter, K. Stellrecht, X. Lin, D. Operario, S. Griesemer, A. Fitch, R. A. Halpin, T. B. Stockwell, D. J. Spiro, E. C. Holmes, K. S. George. (2011) Deep Sequencing Reveals Mixed Infection with 2009 Pandemic Influenza A (H1N1) Virus Strains and the Emergence of Oseltamivir Resistance. Journal of Infectious Diseases 203:2, 168-174
   CrossRef

2. 2

   F. G. Hayden, M. D. de Jong. (2011) Emerging Influenza Antiviral Resistance Threats. Journal of Infectious Diseases 203:1, 6-10
   CrossRef

3. 3

   A. Pizzorno, X. Bouhy, Y. Abed, G. Boivin. (2011) Generation and Characterization of Recombinant Pandemic Influenza A(H1N1) Viruses Resistant to Neuraminidase Inhibitors. Journal of Infectious Diseases 203:1, 25-31
   CrossRef

4. 4

   Meier, Markus H., . (2010) More on Integrated Delivery Systems. New England Journal of Medicine 362:13, 1247-1248
   Full Text

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