Policy makers are beginning to appreciate the fact that only systemic change can effectively change, for the better, the manner of health care delivery in the U.S.; and that anything less would only alter the system's edges - with little or no substantial effect on cost-control, innovation-promotion, effectiveness of reward incentive schemes, coordination and coverage (AHA, 2010). Clinical integration has been found to be crucial to the change needed for the achievement of the aforementioned goals (AHA, 2010). Despite the challenges (legal and otherwise) clinical integration faces, it still is key to health sector reforms.
What is Clinical Integration?
Clinical integration refers to "the coordination of patient care across conditions, providers, settings, and time to achieve care that is safe, effective, efficient and patient-focused" (URAC, n.d.). It mainly focuses on collaborating the operations of different providers to ensure consistency and coordination, hence cost-effectiveness and quality in the delivery of health services (URAC, n.d.).
History of Clinical Integration
Clinical integration efforts were in place even before the term was first defined by the Federal Trade Commission (FTC) in 1996 (Athena Health, 2014). Today's model, however, differs from that which was in place then. The models in the past sought to create integrated delivery networks (IDNs) and physician-hospital organizations (PHOs) with the aim of ensuring greater cost and admission control, facilitating contracts with payers, and improving negotiations (Athena Health, 2014). The models were, however, ineffective and hardly had the infrastructure needed in risk management (Athena Health, 2014). Moreover, there is very little proof that the models achieved their intended objective - providing quality care while containing operational costs; a factor that led to their abandonment (Athena Health, 2014).
The present day's models differ from those of the past in three fundamental ways;
The concept of purchasing and acquiring practices is not relevant to today's strategy; integration is achieved when individual practitioners align with provider networks (Athena Health, 2014).
Today's hospital-physician groups are not open, and demand "that providers maintain a more uniform, high standard of care" (Athena Health, 2014).
Health information technology (HIT) "has evolved to meet new standards of secure, interoperable and comprehensive exchanges" making it easier and cheaper for health care leaders to share information (Athena Health, 2014). They can make use of data aggregation solutions, HIEs and EMRs for faster and more affordable information sharing (Athena Health, 2014).
Goals of Clinical Integration
Clinical integration focuses on expanding the coverage of health services, improving care and quality coordination, rewarding efficient and effective care, fostering innovation within the health sector, and controlling operational costs (AHA, 2010).
Importance of Clinical Integration
Clinical Integration and Health Care Reform
Three fundamental fragmentation scenarios synonymous to the health sector make it extremely challenging for patients to navigate "the health care delivery system at a time when they are most vulnerable" (AHA, 2010, p.2). To begin with, the common physician-hospital relationship model does not ensure optimality in care coordination between the two parties (AHA, 2010). According to the model, practitioners (physicians) rely on hospital staff who are not employed by the hospital for service provision (AHA, 2010). The Civil Money Penalty, anti-kickback and Antitrust Stark laws limit the extent to which hospitals and physicians can interact and influence each other's patterns in cases such as these (AHA, 2010).
Secondly, "most office-based practitioners continue to practice in solo or small" single-specialty groups, which have limited ability to support quality coordination (AHA, 2010, p. 1). This gives rise to a situation where "for every 100 Medicare patients treated, each primary care physician would typically have to communicate with 99 physicians in 53 practices" to achieve coordination (AHA, 2010, p. 2).
Third, patients can readily access health services from post-acute settings and freestanding ambulances, which are either in competition or working complementarily with hospitals (AHA, 2010). Such situations, especially those that involve competition, fragment care and expose patients to substantial risks of duplicative diagnosis and adverse drug interactions (AHA, 2010).
Clinical Integration and New Payment Models
Payment reforms could provide significant boost to the ongoing clinical integration promotion efforts. There have been attempts to replace the fee-for-service system with one that cuts across different types of providers and holds "providers accountable for the quality of care and the resources used to provide it" (AHA, 2010, p. 4). Such a system would promote integration as it would allow for the creation of provider incentives and reward benefits as well as the use of resource management and pay-for-performance tools (AHA, 2010).
Clinical Integration and Advancement in IT
Information sharing is a vital component of clinical integration (AHA, 2010). Congress, in 2009, in passing the HITECH Act, made an authorization for a $36 billion funding for "an electronic health information infrastructure" (AHA, 2010, p. 3). HITECH, moreover, sought to advance additional funding to providers who made 'meaningful use' of electronic health records (AHA, 2010). The Internal Revenue Service (IRS) guides hospitals to "assist physicians in developing electronic health records" (AHA, 2010, p. 3). Although the limited relief from anti-kickback and Antitrust Stark laws does not allow for complete information sharing and subsidization of software and connectivity by hospitals, a number of systems have successfully managed to increase their use of IT (AHA, 2010).
There is room, however, for facilities to "establish the type of information sharing that will support greater clinical integration" (AHA, 2010, p. 4). The development of guidelines, through which physicians can assess their effectiveness in service delivery, could go a long way in facilitating information sharing (AHA, 2010).
Barriers to Clinical Integration
Health facilities face a host of regulatory barriers in their attempt to enhance clinical integration with their physicians (AHA, 2010). The gain sharing-prohibiting provisions of the Civil Monetary Penalty Statute, the anti-kickback and the stark laws are the most significant legal barriers to clinical integration (AHA, 2010, Gosfield & Reinertsen, 2010). Lack of i) practitioner alignment and ii) integration interoperability also pose as serious hindrances to integration (Gosfield & Reinertsen, 2010). Table 1 summarizes the effect of the legal barriers on clinical integration.
i) Legal Barriers to Clinical Integration
What is Prohibited
Antitrust (Sherman Act)
Non-financial and non-integration ancillary agreements, which would give physicians market power.
Hinders physicians from "entering into pro-competitive innovative arrangements because they are uncertain about antitrust consequences" (AHS, 2010, p. 11).
Stark Law (Ethics in Referral Act)
Referral of patients to facilities to which the referrer is financially-linked.
Bans certain arrangements that could improve health care delivery to patients by tying payment to services offered rather than to hours worked
Medicaid and Medicare-induced patient referrals
Brings about "uncertainty concerning arrangements where physicians are rewarded for treating patients using evidence-based clinical protocols" (AHS, 2010, p. 11).
Civil Monetary Penalty
Payments from a facility that induces a practitioner to reduce the services extended to a Medicare/Medicaid patient
Bans any incentive whose result is reduced care, even if such a result improves the quality of care; for instance, low-priced products
Source (AHA, 2010, p. 11)
ii) Lack of Practitioner Alignment
Practitioner alignment, the efficient coordination between physicians and hospitals, is a vital element of successful integration (Kaufman, Hall & Associates, 2012). Clinical integration entails a shift from the current to a new environment, in which case providers are compensated on the basis of results for efficiency, access and quality (Kaufman, Hall & Associates, 2012). This implies that if physicians meet the baseline performance standards, they, together with their facilities (groups), get to enjoy the benefits of shared savings (Kaufman, Hall & Associates, 2012). This is, however, only possible if the actions of physicians are properly-aligned to those of their provider groups (Kaufman, Hall & Associates, 2012).
Entities wishing to pursue physician alignment have three alignment options to choose from; independent physician programs, employed physician programs and clinical integration models - each with its share of advantages and disadvantages (Kaufman, Hall & Associates, 2012)
The Independent Physician Approach: facilities have to formulate options that would enable them to not only support, but align with care providers who prefer being independent (Kaufman, Hall & Associates, 2012). This would involve a hospital contracting with a physician group in an agreement in which both parties define their performance levels and deliverables (Kaufman, Hall & Associates, 2012). Although such an arrangement would be easy to form, and would also be highly flexible to adjustments, it limits the extent to which the hospital can influence the behavior of physicians, control costs, and keep quality in check (Kaufman, Hall & Associates, 2012).
Employed Physician Approach: in this approach, a hospital acquires a private practice and then recruits physicians (Kaufman, Hall & Associates, 2012). Unlike the independent physician…