Cultural Barriers to
Integration
Health center identity as an independent, community-based organization. Participants described health centers’ historical
identity as independent and highly responsive to community needs. To avoid dependence on other institutions and maximize patient choices, health centers maintained relationships with multiple hospital systems. One consortium executive noted that the culture of independence hampered efforts to improve care coordination among its own members.
Tightened networks with a safety net hospital would threaten health centers’ autonomy and their perceived ability to prioritize the needs of their respective communities.Safety net hospitals as providers of last resort, not the providers of
choice. Although health centers have a mission to serve all regardless of ability to pay, leaders from both organization types characterized safety net hospitals as the traditional provider for patients who have no other choices. Health center leadership reported referring uninsured patients to the local safety net hospital but referring insured patients elsewhere whenever possible. Hospital leaders reported that, pursuant to their mission, they have not prioritized strategies
to become more attractive to patients, even if they provide high quality care. One leader expressed concerns that increased strain on hospitals already stretched to capacity is an unintended consequence of these efforts. Investing
in integration may require a shift in hospitals’ traditional identity, which may appear counterproductive to hospitals’ mission as the provider of last resort. Distrust between hospitals and community health centers. Respondents
described how conflicting institutional identities contributed to distrust between safety net hospitals and community health
centers. Health center leaders perceived that safety net hospitals devalued consumer choice and could not be trusted to provide consistently high-quality care. In turn, hospital leaders perceived health centers’ autonomy as overriding collaboration and expressed skepticism as to whether health centers could be trusted to keep patients within the
hospital network. Thus, despite sharing care for disadvantaged patient populations, leaders reported the absence of a commitment to work together. Furthermore, a few interviewees reported increasing competition following expansions in insurance coverage, which could hamper future efforts toward integration.