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What is Clinical Integration?
Clinical Integration (CI) is an effort among physicians, often in collaboration with a hospital or health system, to develop active and ongoing clinical initiatives that are designed to control costs and improve the quality of health care services. Participation in a CI program provides physicians the ability to contract collectively with Preferred Provider Organizations (PPOs) or other fee-for-service health plans without violating antitrust laws.
The characteristics of an effective clinical integration program are:
1) to provide measurable results that
2) are used to evaluate physician performance and
3) result in measurable improvement of that performance.
How does it work?
Participating physicians are required to collaborate with their physician colleagues in the development and adoption of clinical initiatives that will enhance the quality, service, and cost-effectiveness of patient care. This usually includes the use of Quality Performance Measures specific to each physician specialty. For example, primary care physicians initial quality measures could include colorectal screening, BMI screening, tobacco cessation interventions, use of ACE inhibitors in patients with heart disease and diabetes, and measurement/treatment of LDL cholesterol in diabetic patients. Some of the specialty physician measures might involve stellar performance of inpatient core measures for quality. Consequently, every year these measures would be evaluated and new measures added. Physicians would then hold themselves and their colleagues accountable for compliance with these initiatives, including disciplinary and improvement efforts should some physicians fail to meet the benchmarks set by the CI program.
At its heart, clinical integration is teamwork: hospitals, doctors, nurses, and other caregivers all working together to make certain that patients get the right care, at the right time, and in the right place. Much of healthcare today occurs in silos – physicians, therapists, and home health providers all for the most part working in an autonomous manner. Even health care facilities like hospitals tend to work independently from other hospitals and long-term care facilities. The patient is simply passed along when the time comes to move to a different level of care, often with surprisingly little communication and coordination. The driving force behind this inefficiency stems from the fact that all of these different caregivers and entities are paid individually for their services, with little accountability for how they perform them or how they ensure that others do. Clinical integration is aimed at filling in these gaps of care, and more appropriately centering the care on the patient’s needs.
There are a variety of different models for achieving clinical integration. The Federal Trade Commission (FTC) and the Department of Justice (DOJ) have issued opinions to help sort through legal barriers such as antitrust laws, Stark, Anti-kickback statute, and the Civil Monetary Penalty. Most importantly, the integration has to be real. They have suggested that in order to remain compliant, clinical integration programs should:
- use common IT technology to ensure exchange of all relevant patient data,
- develop and adopt clinical protocols,
- review care based upon the implementation of the protocols, and
- put in place mechanisms to ensure adherence to the protocols.
The biggest hurdle for CI programs has been Anti-trust law. These laws govern our nation’s policies on competition to make certain that the playing field remains level for all consumers. The FTC has now ruled on several occasions that appropriately constructed clinically integrated networks of physicians are legal. It has determined that if physicians are working together to improve quality and efficiency of health care delivery, this is a “greater good” than any restraint on trade. Physicians are thus allowed to negotiate pay-for-performance contracts that reward their efforts of improving clinical performance.
There are several nice examples of effective clinical integration programs that have been blessed by the Federal Trade Commission. Favorable FTC rulings include Tri-State Health Partners, MedSouth, and Norman PHO. Advocate Physician Partners in Chicago is one of the largest and most visible CI programs. This collaborative effort includes a network of over 4000 practicing physicians and ten hospitals all working together to improve the value of health care services for patients across several insurance plans.
Physicians and hospitals nationwide are increasingly implementing clinical integration programs as part of their strategies for the future. This has grown beyond reasons of antitrust compliance. They are pursuing clinical integration because they believe in its value proposition. Some examples of this, from the perspective of the major stakeholders, are listed below.
Clinical integration allows physicians:
- the ability to demonstrate their quality to future and current patients,
- the option of choosing the clinical measures against which they will be evaluated and thereby avoiding measures as imposed by health plans,
- enhanced revenue through better management of chronic patients, and
- a legal mechanism to engage in group contracting.
Clinical integration gives hospitals the ability to:
- demonstrate their quality to current and future patients,
- enlist physician support for hospital initiatives, including compliance with core measures, clinical pathways, standardized order sets, and supply chain initiatives,
- develop a better, more collaborative relationship with their medical staff,
- improve performance on hospital pay-for-performance measures, and
- position themselves at an advantage in the market on the basis of quality.
Clinical integration provides patients with:
- better value for their health care dollar,
- a health “partnership” with more effective care management, convenience, and outreach from a trusted source, their physician,
- more accurate and reliable information to support their choice of health plans, physicians, and hospitals, and
- greater stability in their relationship with their doctor and hospital.
Clinical integration gives employers:
- the ability to more effectively manage the health care costs of employees and their dependents through the purchase of better, more efficient health care services,
- increased employee productivity and reduced absenteeism through the better management of chronic disease, and
- more reliable information to support conversion to consumer-driven health insurance products.
Clinical Information Systems are essential to achieve true clinical integration. A big part of clinical integration revolves around enhancing the connectivity between hospital, physician practices, and transitional care. There must be adequate infrastructure for information to be shared and readily available so that patients with chronic conditions can be managed across the care continuum. Clinical practice guidelines are developed to focus on these chronic conditions so that better outcomes can be achieved. This could be accomplished by use of a Health Information Exchange system to follow care of the complex patient from inpatient to ambulatory setting and all of the stops in between.
In addition, a business intelligence software solution should be implemented so that physicians’ performance can be tracked and trended. The CI members would then be responsible for remediating those physicians who do not achieve the expected outcomes. The STVPA is using the MedVentive business intelligence software solution. The MedVentive product is described in further detail elsewhere on this site.
Lastly but importantly, other expected components of IT functionality in use by STVPA caregivers include clinical information systems for computerized physician order entry (CPOE), ePrescribing, and clinical decision support tools. It probably goes without saying that the complex IT infrastructure required to accomplish this is not cheap on costs or manpower.
How does the STVPA save on health care costs?
One of the expressed goals of clinical integration is slowing the continued rise in healthcare costs by improving efficiency of care delivery and eliminating much of the waste. Some specific examples of ways that costs can be controlled while providing better care include:
- getting physicians to agree and adopt best practice clinical guidelines and specific quality performance measures to decrease variation in care,
- prescribing more generic medications, when clinically appropriate,
- enhancing information sharing and connectivity by better utilization of electronic health records,
- focusing on health prevention by incentivizing both caregivers and patients, and
- identifying and better managing chronic diseases such as diabetes, hypertension, and congestive heart failure, and
- preventing over-utilization of emergency room services for patients who would be better treated in an ambulatory or urgent care setting.
Health Reform and ACOs
Clinical integration is an important part of health reform. CMS and other payers are now rewarding and penalizing hospitals for performance with the value-based purchasing program, the hospital readmissions reduction program, and payment reductions for hospital acquired conditions and mortality outcomes. They continue to insinuate that at some point in the near future they will extend these “pay for performance” concepts to include physician reimbursement.
CMS is also driving the creation of Accountable Care Organizations (ACOs). An ACO is a local health care organization that is accountable for 100 percent of the expenditures and care for a defined population of patients. Primary care physicians, specialists, and hospitals go at risk for this population and must work together to provide evidenced-based care in an organized model. Patients must no longer be viewed as acute episodes of care in a hospital, but rather as members of a community that interface with the health care system along many different points. This requires care navigation, patient education, care protocols/guidelines, and aggressive case management, especially for patients with chronic conditions.