The integrated health-care system: reflection and projection.

This paper presents a personal view of the development of integrated, comprehensive health-care systems in the United States. The influence of Federal legislation is described, beginning with the 1950-60s policy objective of Hill-Burton Program administrators to create a number of community-based regional medical centers, each consisting of a range of health services organized by and around community hospitals. Later variations of the concept appeared in such programs as Medicare-Medicaid, Comprehensive Health Planning, the Regional Medical Programs, and the new Agency for Health Care Policy and Research. Based on the cumulative experience of the past, the economic, professional and social climate of the present, with its increasing involvement of the patient/payer/consumer in decisions, and the enhanced inter-organizational coordination emerging from technologies of computers and communication science, the goal of creating comprehensive integrated systems as conceived in the 1950s and 60s may finally be achieved in the 1990s, but in a different form from that envisioned earlier. By judicious exploitation of computer and communication capabilities and the massive knowledge bases evolving from research, the way is eased for patient-centered integration and coordination of services without demanding integration in the sense of ownership or formal control of all the providers within a central organization.