Clinical Integration – The Essence

The term is becoming increasingly popular, much like Population Health a year ago (http://www.drrobschreiner.com/care-delivery/population-health-the-imprecision-of-language/). Journalists are hearing Clinical Integration is necessary for healthcare systems to be successful in value-based payment models (e.g., bundled payments for surgical procedures, Medicare Shared Savings Program for FFS Medicare, or global prepayment in Medicare Advantage). So the next several posts will address various aspects of Clinical Integration.

First, let’s clarify the difference between two similar terms:


Zdenko Zivkovic / Foter / CC BY

Clinical Integration (CI) refers to how geographically separate hospitals, physicians and other healthcare personnel contemporaneously coordinate with each other their separate healthcare activities for the benefit of an individual patient or a cohort of patients.  For example, a middle aged man with acute onset LLQ abdominal pain, fever and constipation is seen by 3 physicians (PCP, Radiologist and General Surgeon) in two locations (rather than three) within a 6 hour period of time (rather than 6 days) that results in a single-stage colon surgery for acute diverticulitis (rather than a two-stage colectomy and colostomy complicated by perforation, sepsis and ICU resuscitation resulting from a 6 day evaluation in a fractionated care system).

Clinically Integrated Network (CIN) refers to financially separate healthcare providers (e.g., hospitals, surgical centers, physician groups, home health agencies) that form a shared legal entity that enables single-source contracting with payors, yet is protected from anti-trust prosecution, in accordance with the 1996 DOJ / FTC rule governing CINs.  The stated purpose of CINs is to facilitate Clinical Integration (CINs do NOT create CI, at best they facilitate its creation). In practice, many just raise local market prices without achieving significant improvement in clinical outcomes (several articles to read for additional information, but here’s something recent http://khn.org/news/medical-prices-higher-in-areas-where-large-doctor-groups-dominate-study-finds/).

The best litmus test for whether true Clinical Integration is being advanced in a particular conversation is to ask this one question: ‘Will the contemplated operational, informational or cultural change reduce the duration of time that elapses between onset of illness (in the case above, acute diverticulitis) and definitive resolution (in the case above, a curative operation)?’  That’s how value is generated for the patient (avoidance of sepsis, intubation and rehab) and delivery system (lower total cost of care, higher brand).

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