by Keith Moore and Dean Coddington[1]

Who should play a role in healthcare integration? And how should they play together?

For many, the term “healthcare integration” evokes an image of physicians and hospitals working closely together – using a common electronic health record, working together to minimize transaction costs and provide the best combination of inpatient and outpatient care.  For some, integration evokes an image of payers, health systems, and physicians aligning incentives to reduce costs.  For some, integration evokes an image of many hospitals and physicians working together to cover a large geographic area – with the most quaternary procedures concentrated in one place and with more common cases spread conveniently across the service area.

We have written often about the opportunities and achievements of the classic integrated health system.  Whatever one’s current image of healthcare integration is, however, it may be time to promote a new image.  We propose the concept of a “Big Tent” – with many players under the tent — carrying out a broad set of services, with an array of business models, for the benefit of a diverse population.

Under the Big Tent

Today’s Big Tent needs to encompass behavioral health – and social determinants of health – and electronic means of communicating and treating health needs – and places where entrepreneurs can interact with traditional sellers and buyers of care –and new structures for dealing with closely related issues such as housing – and new forms of financial and strategic alignment. Those who deal with these issues and others need to recognize and coordinate more effectively with each other.

The Big Tent in healthcare includes many types of organizations and cultures.  For example, there are entrepreneurs hoping to go public one day — and social services providers who hope to keep their doors open another year — and health systems that are the largest and most stable pillars in their communities – and commercial payers who listen to calls for them to change and/or be replaced by a public option.  There are national organizations, unique local organizations, governmental entities, and philanthropies under the Big Tent.

In some communities, elements of the Big Tent are working together on other issues – for example in Nebraska and Colorado they are coming together on workers’ housing.[2]  In Florida and Texas, they have been together on disaster relief.[3]  Many states have overall strategies for low income housing, persons without homes, and disaster relief that go well beyond their integration and coordination in healthcare.

In some communities, those who serve the homeless, Medicaid recipients, Medicare members, commercial plan members, and concierge patients are the same providers.  However, in many communities, those who serve these different population segments don’t even know each other.

Pros and Cons under the Big tent

The pros are large and compelling.  There are substantial opportunities to leverage sources of funds (Medicaid, Medicare, commercial payers, health system investments of time and dollars) in more effectively overall financial model. One outcome can include significantly lower total costs of care.

The largest cons are the time and focus required to develop joint approaches, and to accommodate potential differences in organizational cultures and decision-making.  The cons are not insignificant, but they are dwarfed by the potential gains.  The players under the Big Tent may include a major health system, or it may include several health systems.  In either case, it includes a mix of other players.

Next Steps under the Big Tent

Here is one approach for advancing a Big Tent:

  1. Identify common opportunities and the players who should be involved. Health systems and policymakers can promote the wide range of opportunities for new forms of integration.  In some states, this means building on current healthcare associations, colloquiums or philanthropic initiatives.  In other cases, healthcare leaders can join and expand existing efforts in other areas — such as housing, economic development, or social services.
  1. Develop an initial strategy and financial approach. Most overall strategies (i.e., Big Tent strategies) will begin by identifying needs, inventorying existing initiatives, understanding gaps, and developing priorities.

A promising early step is to “rough out” an overall financial plan.  Often dollars from one source can be leveraged by dollars from another source.  The result is often not only a more cost effective result, but also a much closer relationship between leaders of different types of organizations.

  1. Further integrate behavioral health and physical health. Behavioral health is an especially ripe area for Big Tent initiatives.  Health systems and/or payers can usually take the lead on stronger integration. The total costs of care can be reduced if the right patients (those in need) receive the right form of behavioral health assistance at the right time and the right place.  Payers benefit from this, as do employers, as do social services organizations and the public entities that fund them.

One of the most efficient ways to link behavioral health with those who need it is through physical health providers (especially through primary care physician practices).

Today, there is a mismatch between the beneficiaries of further integrating mental health services (payers, employers, and other public entities – as well as patients) vs. those who could best facilitate the integration (primary care physicians).

The Big Tent has a role to play. Some employers’ Employee Assistance Programs (EAPs) help.  Also, CMS’ Medical Home program helps.  But these are small efforts relative to the potential for integration.

Big Tents Differ

Who organizes and/or leads a Big Tent?  Many begin as a collection of smaller tents.  For example, two ACOs agree to share many elements of social support infrastructure.  Or, three health systems form an infrastructure joint venture.  Or, all health systems plus several other groups within a state agree to work together on a range of issues – including homelessness and healthcare quality measures.

Whereas the classic healthcare integrated system includes hospitals, physicians and payers under a single ownership, the typical Big Tent includes many forms of legal entities – public, not-for-profit, for-profit, and other.  However, Big Tents need to address the same issues as a classic integrated health system.  For example, how will incentives be aligned, how will financial flows work, how should governance and decision-making be implemented, joint governance, how should leaders be trained, how should success be monitored?

There is a challenge in managing across different cultures – e.g., the differences between an entrepreneurial culture, a local government culture, an academic health system culture, a physician practice culture. Cross-cultural, cross-legal management is an art form.  Who will be the successful artists, and what can they teach others?

Start a Big Tent

Broad approaches – involving a range of entities under a Big Tent – make sense.  They can be flexible, and adjust to local circumstances.  They can accomplish more; they can be more cost effective and they can lower the total cost of care in a community.  It’s a logical next step in integrated healthcare.


[1] A version of this article appears in the October issue of HFM – the publication of the Healthcare Financial Management Association.

[2] For example, see, and

[3] For example, see