The Doctor’s Advocate | First Quarter 2014

Integrated Delivery Systems: A Crucial Outgrowth of Healthcare Reform

Brian M. Parker, MD, Medical Director of Clinical Risk Management, Cleveland Clinic

The dictionary defines culture as “the set of shared attitudes, values, goals, and practices that characterizes an institution or organization,” but, in reality, culture is “the way we do things around here.” With the changes occurring in our healthcare system, the culture at most healthcare institutions can be only one thing: uncertain. We don’t know exactly how the broad emphasis on value rather than volume will ultimately affect us. Timelines add more uncertainty; a number of milestones that are part of the Affordable Care Act have been modified or missed.

Despite many moving parts within the legislation—including the speed of reform and how state exchanges will actually function—we can identify many additional factors that will also influence the changes: an aging population, which by 2040 will include more than 80 million Americans over age 65; a soaring national debt that’s driven in significant measure by government payments for healthcare; and public expectations of virtually unlimited healthcare choices on a McDonald’s budget.

These factors are fueling the drive toward healthcare consolidation. An Integrated Delivery System (IDS) is a rationalized model of healthcare designed to improve outcomes and reduce costs. The model offers the promise that physicians could practice medicine without having to bear a disproportionate administrative burden.

For patients, it moves closer to the ideal of accessible comprehensive care delivered consistently.

Cleveland Clinic had long resisted this crucial shift, previously priding itself on episodic care through local, regional, national, and internal referrals without significant interest in providing longitudinal care. But, starting in the 1990s, we realized we must also provide patient population management within Northeast Ohio. The electronic medical record (EMR) greatly facilitates this process, though we adopted it in stages, and it took time for all physicians to come onboard. Physician buy-in will be just as pivotal to the success of our IDS.

In addition to the physicians who work exclusively for Cleveland Clinic, we also have the Cleveland Clinic Community Physician Partnership (CPP), a group of independent doctors with staff privileges at our hospitals. This hybrid employed-physician model means that all CPP physicians are part of a quality alliance built around the EMR (which patients can also access) to align care with Cleveland Clinic’s standards and track outcomes and metrics. Incidentally, CPP has endorsed The Doctors Company as its exclusive medical malpractice insurer.

Some healthcare systems purchase multiple physician practices without understanding what an employed physician model really entails. They are, essentially, buying referrals without managing the groups in a meaningful, aligned manner. A true partnership occurs when both sides, doctors and system, have skin in the game.

Another pitfall to creating a sustainable network for delivery and care is integration for integration’s sake, where a decision to acquire a facility comes with the expectation that the new facility’s culture will immediately change to that of the mother ship. Obviously, if you bring in a hospital that doesn’t have an EMR, you’ll integrate it into your EMR. But networks wanting a total transformation need to take a hard look at how they can make the new facility operational and successful. On top of that, newly acquired facilities don’t want to feel stripped of their culture, and they will be demoralized if told to be just like you.

Clinical integration, which combines primary care physicians and a full range of specialists to create a continuum of care, is emerging as a cornerstone of every solid IDS. In Northeast Ohio, only a few private hospitals haven’t been incorporated into our system or affiliated with other large groups. Joining bigger networks gives individual hospitals an opportunity to leverage tools, such as the EMR, or to do their own benchmarking, but the mere act of merging isn’t the most important part—it’s creating an affiliation that allows the larger network to examine how they operate and see what others do well. It’s the transfer of both patients and intellectual capital.

Optimizing this intellectual capital transfer facilitates cost repositioning, a focus that has essentially become the mantra of healthcare reform. But cost repositioning can’t be confused with service line cost management—which is the attempt to drive down the cost of one type of procedure or episode of care. Instead, it entails understanding the cost structure for the entire population of patients you are managing so costs can be reduced without compromising outcomes. A good definition of value is quality divided by cost, so the more you increase quality and maintain or reduce cost, the more you’ll improve value.

This is another area in which engaging physicians is essential regardless of the practice model. The care paths many institutions are developing to streamline costs—which in general are good and useful measures—run the risk of destroying the art of medicine and the value of professional experience. But realistic care paths, like those we’re developing at Cleveland Clinic, are meant to allow physicians to use their best clinical judgment wherever appropriate. We also recognize that patients and illness don’t always behave the way we expect, so care path designs must be flexible enough to work well in the world physicians confront every day.

For Integrated Delivery Systems to succeed, everyone involved needs to understand the principles of the organization and to share a vision of success that includes a commitment to medical excellence based on the highest values. Bringing together multidisciplinary teams, using evidence-based approaches, and encouraging marketplace competition are all necessary for an IDS that can carry our healthcare system forward with improved outcomes and sustain-able costs.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

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