Integrated delivery systems: non fait accompli

This article explores the themes that advocates of integrated delivery systems (IDSs) hoped would allow them to favorably leverage the final stages of managed care evolution: revenue generation, cost control, and quality improvement. In reality, however, IDSs have been highly unsuccessful in growing market share, competing against other managed care forms, and integrating delivery systems--their raison d'être. Two key concepts in global theory, risk and episodic management, are introduced, and utilized to show how IDSs addressed these fundamental properties inappropriately. As a result, financial results and system performance have been dismal. A prognosis is given as well as suggestions for improvement through risk bifurcation, global fees, and integrated episodes of care.