MPA | Pharmacy News

By Tiffany Jenkins, Pharm.D., BCACP, clinical pharmacist, Affinia Health Network, Muskegon

 

Clinical integration initially arose over 20 years ago and early integration efforts were focused on creating a model to give hospitals and health-systems greater control over admissions, costs and contracting with payers. There are a number of definitions attributed to clinical integration, but the Department of Justice (DOJ) and Federal Trade Commission (FTC), as the regulatory bodies, defined clinical integration in 1996 as follows: "[clinical] integration can be evidenced by [a physician] 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."1 The DOJ and FTC became involved to ensure organizations were not creating these networks to just simply bargain for better rates and contracts, but to also improve quality of care for a population.

 

Early clinical integration efforts were focused on creating physician-hospital organizations (PHOs) or integrated delivery networks (IDNs). While these organizations still exist, some have evolved into clinically integrated networks (CINs). The CIN model is focused on the quadruple aim: reducing care costs, improving the health of the population, enhancing the patient experience and lessening physician burden.2 The business model of a CIN provides the infrastructure support for the network and ensures the following core competencies and capabilities are in place:3

  • Leadership and Governance: physicians from the network play a key role in the leadership of the CIN.
  • Integrated physicians: physicians and providers are engaged in the work, developing protocols and workflows.
  • Integrated care coordination network: consistent, evidence-based care is provided to patients and they are managed across the care continuum.
  • Data driven with analytics support: using data to measure network performance and to drive improvements.
  • Comprehensive networks: necessary services are available within the network (acute care, primary care, specialist care, etc.).
  • Payer alignment: work to ensure the best contracting possible and provide oversight on the performance of these contracts.

When reviewing the definition of clinical integration and better understanding the competencies required of a CIN, there are a number of areas where pharmacy intervention can play a role. Pharmacists are uniquely positioned to influence prescribing patterns, suggest lower cost alternatives and coordinate services with physician offices such as disease management or vaccinations. These types of interventions serve the patient as an individual, but also begin to move toward population health management which is essential to the success of a CIN. Many CINs are recognizing the advantage of having pharmacy input, especially as pharmacy costs continue to rise.

 

As always, if interested in learning more about ambulatory pharmacy, how to get a practice started, and finding practice resources, be sure to check out the MSHP Ambulatory Care toolkit at www.MichiganPharmacists.org/ambulatorycare/practicetoolkit.  

 

References

1. U.S. Department of Justice and Federal Trade Commission. Statements of Antitrust Enforcement Policy in Health Care. FTC website. https://www.ftc.gov/sites/default/files/attachments/competition-policy-guidance/statements_of_antitrust_enforcement_policy_in_health_care_august_1996.pdf. August 1996.

2. Bodenheimer T, Sinsky C. “From Triple to Quadrule Aim: Care of the Patient Requires Care of the Provider.” Ann Fam Med. 2014;12(6):573-76.

3.  PYA Healthcare Consultant and Audit & Accounting. Clinically Integrated Network: Who, What, When, Where, Why, and How?” PYA website. http://info.pyapc.com/hubfs/White-Papers/Clinically-Integrated-Networks-White-Paper-PYA.pdf. April 2013.

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