Structural factors and integrated care interventions: is there a role for economists in the policy debate?

Over the past few decades, integrated care (IC) has been emphasised as solution that promises to make the supply of health care more effective and efficient and for managing consumers’ demands for services. Yet, as decades of empirical evidence now demonstrate, the more Panglossian predictions of IC’s promise have been frustrated. Indeed, the weight of evidence from papers in the peer-reviewed literature—across all relevant disciplines—demonstrate that IC interventions often have modest effects on their intended targets. We argue that a range of structural factors, that are not typically emphasised by non-economists who write on this topic, are the key to understanding how and why particular IC interventions tend to fail (or succeed). We emphasise the unique perspective and comparative advantage that economists can bring to bear on this topic by incorporating the role of systemic and institutional structures and the incentives that are inherent in them, as central to analyses of what types of IC are (un)likely to work. In particular, some of the structural elements of extant health systems are more of the nature of constraints than fungible instruments of health policy. Our objective is to develop an economic characterisation of the microeconomic problems of different types of IC initiatives and their implementation, followed by a taxonomy of them that pertains directly to commonly-observed differences in health system characteristics (which we label “macroeconomic” factors). We argue that interventions in the set referred to generically as “IC”, are quite heterogenous and that between countries, and sometimes even within them, health systems are also characterised by considerable heterogeneity. Taking the latter as more-or-less exogenous, we seek to illustrate how these microeconomic and macroeconomic characteristics combine to make particular kinds of IC interventions more successful and more likely to be effective and sustainable in some health care systems than in others.