Integrated care experiences and outcomes in Germany, the Netherlands, and England.

Care for people with chronic conditions is an issue of increasing importance in industrialized countries. This article examines three recent efforts at care coordination that have been evaluated but not yet included in systematic reviews. The first is Germany's Gesundes Kinzigtal, a population-based approach that organizes care across all health service sectors and indications in a targeted region. The second is a program in the Netherlands that bundles payments for patients with certain chronic conditions. The third is England's integrated care pilots, which take a variety of approaches to care integration for a range of target populations. Results have been mixed. Some intermediate clinical outcomes, process indicators, and indicators of provider satisfaction improved; patient experience improved in some cases and was unchanged or worse in others. Across the English pilots, emergency hospital admissions increased compared to controls in a difference-in-difference analysis, but planned admissions declined. Using the same methods to study all three programs, we observed savings in Germany and England. However, the disease-oriented Dutch approach resulted in significantly increased costs. The Kinzigtal model, including its shared-savings incentive, may well deserve more attention both in Europe and in the United States because it combines addressing a large population and different conditions with clear but simple financial incentives for providers, the management company, and the insurer.