Healthcare: Clinical Integration
Item Page
What is clinical integration
History of clinical integration
Goals of clinical integration
Importance of clinical integration
Health reform
New payment models
IT advancement
Barriers to clinical integration
Legal barriers
Lack of practitioner alignment
Lack of interoperability
How to achieve success in clinical integration
Incentive alignment
Knowledge alignment
Behavioral alignment
The future of health care systems
Physician acquisitions vs. clinical integration
HIEs -- solution to clinical integration?
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...
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