Clinical integration is an effort between physicians and a hospital or health system to develop a coordinated system of care designed to improve quality of care and reduce health care cost through improved efficiency.
Achieving clinical integration also provides a method of collective contracting without violating antitrust laws. The drivers for this are the failure of managed care and risk based contracts to improve the quality of care or reduce cost.  There is increasing evidence that large, well-established, organized systems have the ability to perform efficiently and cost-effectively while delivering high quality care 2,3 There are increased demands for lowering cost from the government, employers, patients, and insurers. There is also increased demand for quality of care such as the ever increasing number of CMS quality indicators that will be used to determine payment.
Models for clinical integration
There are a variety of different models for achieving clinical integration, and the Federal Trade Commission (FTC) and the Department of Justice (DoJ) have been asked for definitions in order to assist in overcoming legal barriers such as the Civil Monetary Penalty, Stark, anti-kickback and antitrust laws. In a 1996 report the FTC stated “integration can be evidenced by the network implementing an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality.”4
More recently a combined report by the DOJ and FTC stated “Commentators primarily focus on four indicia of clinical integration:
- the use of common information technology to ensure exchange of all relevant patient data
- the development and adoption of clinical protocols
- care review based on the implementation of protocols
- mechanisms to ensure adherence to protocols.” 5
Clinical Information Systems are essential in order to achieve true clinical integration. Clinical practice guidelines are usually developed which often focus on certain chronic clinical conditions. There must be adequate infrastructure for information to be readily available for patient care so that expected outcomes can be achieved. This could be accomplished through use of a Health Information Exchange or single clinical system. These outcomes usually include measures of cost, quality, and utilization that the physician is evaluated against and compared to peers. The performance monitoring of these outcomes usually also involves some type of corrective action for those physicians not achieving the expected outcomes. It is anticipated that clinical integration would rely heavily on the use of clinical informationsystem (CIS) functionality such as computerized physician order entry (CPOE), ePrescribing, and clinical decision support to achieve the desired outcomes.6 To be successful clinical integration must also provide communication between hospital and physician offices and between PCP and specialty practices. The practice model may range from independent network physicians with network contracts to an employed PCP and multispecialty group practice.
Clinical integration is as important part of health reform, as health reform brings a hospital value-based purchasing program, a hospital readmissions reduction program, and payment adjustments for conditions acquired in hospitals. 7 It also brings the concept of Accountable Care Organizations (ACOs). An ACO may be defined as a local health care organization that is accountable for 100 percent of the expenditures and care for a defined population of patients, which may include primary care physicians, specialists and hospitals working together to provide evidence-based care in a coordinated model. 8
In the Tri-State Health Partners FTC Advisory Opinion, the FTC stressed the importance of infrastructure and program capability for integrating the provision of care and achieving efficiencies in the context of clinical integration. It noted that there needs to be significant interaction and cooperation by and among physician members in the treatment of patients covered under a clinical integration program. Elements of a clinical integration program can include a large closed panel of providers committed to practicing evidence-based medicine standards and clinical guidelines developed or tailored by the program’s participants, maintaining continuity of care through a within-network referral policy, requiring use of information technology, including EHR, to coordinate care, effectively communicate among network providers, eliminate unnecessary duplication of tests, and collect performance data. Additional elements are establishing mechanisms to collect and evaluate treatment and performance data, requiring broad participation of physicians in various aspects of the program’s development, implementation and ongoing operation, and establishing procedures and mechanisms to provide feedback on individual and group physician performance. 9
In clinical integration models, physicians must agreed to certain practice and referral constraints, as well as to be subject to a variety of monitoring, oversight, and remedial activities by the network, in order to assure that the anticipated integration and efficiencies of the program can be achieved. 10 Case management for patients with chronic conditions is important in clinical integration systems, as well patient education, patient care protocols and guidelines, and quality of care reviews for both risk and nonrisk patients. 11
- Morrisey MA. Alexander J. Burns LR. Johnson V: The effects of managed care on physician and clinical integration in hospitals. Medical Care. 37(4):350-61, 1999.
- Gillies RR. Chenok KE. Shortell SM. Pawlson G. Wimbush JJ: The impact of health plan delivery system organization on clinical quality and patient satisfaction. Health Services Research. 41(4 Pt 1):1181-99, 2006.
- Shields MC. Sacks LB. Patel PH: Clinical integration provides the key to quality improvement: structure for change. American Journal of Medical Quality. 23(3):161-4, 2008.
- Statements of Antitrust Enforcement Policy in Health Care. Department of Justice. http://www.justice.gov/atr/public/guidelines/0000.pdf.
- Improving Healthcare: A Dose of Competition. Federal Trade Commission. http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf.
- Chaudhry B. Wang J. Wu S. Maglione M. Mojica W. Roth E. Morton SC. Shekelle PG: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine. 144(10):742-52, 2006.
- H.R. 3590, 111th Cong. 2009, “Patient Protection and Affordable Care Act,” Washington, D.C.: US Senate 2009 http://www.democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf.
- Deloitte, Accountable Care Organizations: A new model for sustainable innovation. Washington (DC): Deloitte Center for Health Solutions. 2010 Jan. 31 http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/US_CHS_AccountableCareOrganizations_041910.pdf.
- TriState Health Partners, Inc., FTC Advisory Opinion (2009) http://www.ftc.gov/os/closings/staff/090413tristateaoletter.pdf.
- Greater Rochester Independent Practice Association, Inc., FTC Advisory Opinion (2007) http://www.ftc.gov/bc/adops/gripa.pdf.
- Report of L.P. Casalino, February 20, 2004 http://publish.healthlawyers.org/Events/Programs/Materials/Documents/PHY10/demuro_casalino.pdf.