Clinical Integration

Report from Rowena Bergmans
VP Clinical Integration & Population Health

Clinical Integration, what is it and what does it mean for the average physician?

Lets face it, the environment for a practicing physician is rapidly changing. The American healthcare system is transitioning from a traditional FFS care delivery model in which hospitals, physicians and providers are paid based on volume of services provided, to one in which physicians and hospitals will be measured collectively and reimbursed based on performance and financial outcomes. More than ever the ability to meet these new challenges will be predicated on team based care models and clinically integrated networks. Physicians who participate in clinically integrated networks (CIN) are accountable to each other for both the cost and quality of care delivered whether they own it or not.

Clinically Integrated Networks (CIN) - Defined
Multiple organizations from Utilization Review Accreditation Commission (URAC) to the Federal Government have offered formal definitions of clinical integration. The Advisory Board describes clinical integration (CI) as a physician alignment model that allows hospitals and physicians to organize into a single network focused on performance improvement. Although there are many definitions of CI, all definitions have four key foundational elements in common:
    Physician led governance and leadership
    information sharing
    redesigning care delivery models
    performance monitoring.

Physician Leadership
Transitioning to a delivery model that compensates for value vs. volume will take a dramatic cultural shift in how care is delivered. The only way this is going to be accomplished is through strong physician leadership. It is imperative that the individuals who are responsible for delivering care are driving the changes needed. A CIN must have a formalized, physician led governance body that is responsible for overseeing all activities of the network. Questions that a physician led governance body might ask themselves include, what do we intend to do together to improve the health of individuals or populations? How will we be collectively motivated to achieve cost and quality goals? And, what are the consequences for physicians who are sub-performers? These are but a few questions that our physician leaders will need to find answers to when transitioning to a clinically integrated network.

Information Sharing
Robust information sharing is essential to the operations of a clinically integrated network. A CIN must have health information systems in place that has the ability to aggregate and communicate information across the network for decision making which includes: real time clinical data sharing, provider communication, patient identification for care collaboration and management, system usage by network providers, and decision support at point of care. Our ability to communicate patient/provider experience across the continuum will enhance our efforts to deliver care that is efficient, safe and effective.

Redesigning care delivery models
Under the affordable Care Act it is anticipated that 10 million more Americans will enter the healthcare system. Add that to an existing primary care physician shortage and an aging population and you are left with a crisis. In order to meet the demands of these new realities, clinical networks will need to redesign how care is delivered. A focus on Patient Centered Medical Homes (PCMH) with team based care models allows physicians to focus on the needs of patients who have multiple co-morbidities. Additionally, the PCMH model also allows care managers to provide daily contact for those who have the highest needs as well as the ability to risk stratify patient populations so we are wisely targeting patient with appropriate resources rather than a one size fits all model. All these efforts will help meet the needs of our patients. Success of these new models will depend on our ability to coordinate care across the continuum to achieve care that is safe, timely, efficient, equitable and patient/family focused.

Performance monitoring
Finally, a CIN must be able to report on efficiency and quality outcomes for their patient populations. These reports include data representing provider access, availability to supply care, clinical performance, patient satisfaction and financial performance. Increasingly, CMS and private payers are linking compensation to value-based outcomes as illustrated by unnecessary readmissions and physician cost performance. This is true for both clinically integrated networks and independent providers.

An aligned, clinically integrated network is critical to our continued success, as purchasers of care are increasingly demanding greater patient value. How successful we are in building the network will depend on our ability and willingness to collaborate with payers, patients and one another. There is much work to get done with many challenges facing us but by speaking with one voice we can provide the strategic direction and leadership needed to achieve our goals.

Rowena Bergmans