“Fragmentation” – the breakdown in communication among many providers treating a single patient, such that multiple decision makers make a set of health care decisions that would be made better through unified decision-making1 – is frequently cited as a major problem in the US health care system.2 It plagues both the payment system (which has multiple payers) as well as the delivery system (which has siloed providers). This chapter focuses on the latter problem of fragmentation among care providers and calls to correct it via “care coordination.” The problem is not just provider fragmentation, however. It is also the lack of clarity regarding what care coordination (the proposed solution) means, what benefits it confers, and how to do it.

There has been growing interest in the vertical integration of physicians and hospitals during the past decade, as evidenced by multiple literature reviews and research investigations.1 Historically, physicians operated small firms that provided “physicians’ services” to patients who sometimes used facilities provided by separate hospital firms at which many physicians would have “privileges.” This interest in combining the two types of organizations culminated in a December 2020 issue of Health Services Research devoted to the topic that expressed surprise (and disappointment) that integration is not “a miracle cure”.2 Just months earlier, two of the major proponents of vertical integration published a study in the August issue of Health Affairs that came to a similar, “startling” conclusion: the financial integration of physicians and hospitals (e.g., via employment) had no impact on their clinical integration (and perhaps none on quality).

Introduction

The Aravind Eye Care System (Aravind) is a massive network of ophthalmologic hospitals and primary eye care centers in the state of Tamil Nadu in southern India, joined by educational and research institutes, community outreach programs, an eye bank, and a manufacturing arm for lenses. Aravind is famous for its immense contributions to provision of healthcare to the poor. Over the course of its history, Aravind has treated millions of impoverished people in need of eye care. Most remarkably, Aravind has found ways to deliver this care in a financially profitable way.

This history constitutes one of the greatest success stories of providing business solutions to the “bottom of the pyramid,” or BOP (see Chapter 11). The BOP refers to the poorest and largest segment of the population. This is a challenging population segment to serve for several reasons: they have been traditionally underserved, and thus have greater healthcare needs; they have few resources (both capital and human capital); they are a dispersed and heavily rural population; and they enjoy few logistical supports to access care. As a result, the BOP has traditionally not been seen as a favorable customer base. Recently, however, they have begun to attract attention as a viable target for generating revenues and profits. Serving them requires unconventional and innovative strategies.

Aravind's experience in serving this segment has provided both inspiration and valuable lessons for healthcare providers throughout the developing world who wish to reach out to the impoverished masses. This chapter chronicles Aravind's past and present roles in the Indian healthcare space, drawing implications both for Aravind as it looks into the future and for other organizations that wish to provide healthcare to the bottom of the pyramid.