Does Clinical Integration Reduce Risk, Lower Cost of Care?
September 13, 2016by
One of the priorities driving the Patient Protection & Affordable Care Act of 2010 is the need to rein in the exorbitant costs associated with the world’s most expensive healthcare system. One of the ways in which the reform legislation aims to achieve this goal is by incentivizing disparate physicians, hospitals and other ancillary healthcare entities to work together to provide better medical outcomes at a lower cost by reshaping the reimbursement model away from one rooted in fee-for-service and toward one based on bundled payments for demonstrating value to a population of patients. This requires clinical integration across the continuum of care. Clinical integration refers to the coordination of care across a chain of services, including preventive, outpatient and inpatient acute hospital care as well as post-acute assistance such as skilled nursing, rehabilitation, home health and palliative care, to improve the overall value of the healthcare provided. Proponents say an improved coordination of care can curtail adverse medical outcomes, improve the health of a population, reduce per capita costs and improve the overall patient experience, but this requires relevant ongoing patient data being documented in a longitudinal health record accessible by providers at the point of care. Under the Affordable Care Act, both the federal government and commercial payors have started to move toward value-based reimbursement. Those entities able to demonstrate effective clinical integration are rewarded by the Centers for Medicare & Medicaid Services (CMS) with a share of the cost savings generated by increased efficiency. Evidence of effective clinical integration has also been used as a compelling tool for groups and health systems when negotiating contracts with commercial payors. Critical to realizing reimbursement incentives or negotiating more favorable contracts is the collection of even more data necessary to track quality measures as well as account for and manage shared financial incentives. Not only are CMS and private payors rewarding integration, a number of medical professional liability insurers are offering premium credits for clinically integrated physicians on the assumption that the improved coordination of care will equate to a lower risk profile. To date, there is no empirical data indicating clinical integration alone leads to overall improvement in quality of care or reduced liability risk, and there exists evidence indicating that some of the requirements of clinical integration could actually increase liability risk. Data Collection, Physician Burnout and Dangerous EHR Workarounds To support the new reimbursement models, a clinically integrated healthcare system must manage a vast network of public and private information used by various entities in order to monitor quality and cost. On the clinical end, physicians are responsible for entering patient data into an electronic health record (EHR) repository, making it available to all healthcare providers in the network via a health information exchange that encourages communication along the continuum of care. This exchange of information should eliminate the duplication of services, allow for the automation of trends in vital signs and lab results, and help mine for gaps in care, such as an overdue colonoscopy or mammogram, allowing for a medical team intervention. The upside of collecting more data is evident, but a number of studies have indicated that the increased clerical burden this places upon healthcare providers is contributing to increased physician burnout and the use of dangerous EHR workarounds, such as copy-and-paste practices where previous EHR entries are cloned and inserted into a new progress note as well as disabling or overriding burdensome safety alerts, to save time and increase efficiency. A Mayo Clinic survey of 6,375 physicians, published in May, found that those physicians who employ EHRs and are responsible for computerized physician order entry experienced 33-percent-lower professional satisfaction and a 29-percent-higher risk of burnout. A recent Rand Corp. study of physician satisfaction, conducted on behalf of the American Medical Association, determined the current state of EHR technology and its requisite time-consuming data entry “significantly worsened professional satisfaction in multiple ways.” The correlation between physician burnout and medical error has been well established, and an uptick in liability claims related to EHR issues is beginning to appear in medical malpractice claims data. According to a recent survey of medical professional liability insurers about EHR-related medical liability claims, conducted by the medical malpractice insurance industry trade association PIAA, 53 percent of respondents reported they had seen EHR-related claims. Seventy-one percent of respondents cited copy-and-paste workarounds as the most common source of a claim allegation. While, in theory, the information-sharing benefits of EHR-based clinical integration should improve care continuity and reduce the risk of medical errors, a 2015 study by the National Academy of Social Insurance (“Integrated Delivery Networks: In Search of Benefits and Market Effects”) found “little evidence that integrating hospital and physician care has helped to promote quality or reduce costs.” Other Liability Issues In addition to the risks associated with a heightened clerical burden and physician burnout, clinical integration presents other potential avenues for increased liability.
- Because CMS and private payors are incentivizing cost containment with shared savings and higher reimbursement, physicians participating in a clinically integrated healthcare system open themselves to claims of profit-motivated negligence. In other words, in the event of a negative outcome, a plaintiff attorney could make the charge that when the clinically integrated physician refused to order a test or provide a service, he or she was negligently prioritizing cost savings over patient safety, contributing to the adverse outcome.
- When a patient suffers an adverse medical outcome in a clinically integrated health system, it is reasonable to assume the medical liability claim will use the shotgun technique—where any physician, employer or related entity remotely connected to the adverse event gets named in the claim. This effectively increases the risk profile for each member of a clinically integrated healthcare delivery team. Sorting out who is responsible for the negligence is often a murky endeavor. This will be especially problematic in states that have not reformed joint and several liability.
- Because the Affordable Care Act’s Medicare Shared Savings Program requires clinically integrated systems have in place procedures and processes to promote evidence-based medicine, it could be argued by a plaintiff attorney that clinical integration creates a higher standard of care than exists for non-integrated physicians.