Chief Operating Officer, Baptist Health

Dissertation Title

The Effectiveness of Clinical Integration: The Relationship between Evidence-Based Clinical Processes, In-Network Utilization and Clinical, Service and Efficiency Outcomes

Dissertation Abstract

The evolving U.S. health care system continues to steer healthcare organizations and integrated healthcare delivery networks (IDNs) to function as population health networks and ACOs. Policymakers, payers, health care leaders and consumer groups are advocating that IDNs clinically integrate processes and structures under the assumption that they will improve the clinical outcomes for a population, reduce the health care spend, and enhance the patient experience. Relatively little research has tested this assumption, however, due in part to the challenge of finding enough cases or relevant data to rigorously examine the relationship between clinical integration and outcomes. With various models of ACOs in place since 2001 and several states developing payer administrative databases, we are now in a position to test these assumptions. Thus, the purpose of this study was to examine the relationship between integration structures, clinical integration processes, and quality, service and efficiency.

This study examined primary care physicians within a single IDN. The study included 487 of the IDN employed physicians who have the specialty of family practice or internal medicine. To ensure consistency of measurement both within and across physicians, a specific subset of clinical disease states were included in the study: diabetes, hypertension, ischemic heart disease and asthma. Three separate ordinary least squares linear regression analyses were conducted to analyze the relationships between IDN clinical integration processes, in-network utilization, and quality, service and efficiency outcomes. The study also controlled for a number of physician characteristics; including age, tenure at the study IDN and specialty, and environmental characteristics; including the percent of managed care penetration, presence of ACO participation by competitors (Pioneer, MSSP, none), and market share of practice.

This study found that physicians’ use of evidence-based clinical guidelines, which are one element of IDN clinical integration processes is positively associated with better clinical quality outcomes and service, while physicians’ in-network utilization was positively associated with better efficiency. And, a physician with higher levels of clinical integration processes AND higher in-network utilization had even higher clinical quality outcomes.

These results suggest that clinical integration is effective, but not necessarily interdependently, but rather through parallel strategies of IDN clinical integration process implementation and in-network utilization. These findings highlight a number of challenges and opportunities for policymakers and practitioners interested in such approaches for achieving sustained, superior Triple Aim performance.