Clinical Integration Can Mean Many Things

Article excerpt

The Federal Trade Commission and the 'U.S. Department of Justice have said that the "rule of reason"-a relatively lenient approach to antitrust law-will be applied to a clinically integrated physician network, even if the network doesn't have any risk-sharing contracts. But what constitutes clinical integration? "It remains a gray area, open to a lot of interpretation," says Donna D. Fraiche, who chairs the health-law-practice group of New Orleans-based Locke Purnell Rain Harrell.

Last August, FTC and Justice issued a joint communication clarifying the antitrust law's health-care provisions. To help the industry understand what was meant by clinical integration, the agencies offered the hypothetical example of an IPA with primary-care physicians and specialists operating in a medium-size city. Fraiche analyzed the example for The IPA Association of America. She found 14 characteristics that, in the eyes of the federal agencies, help define the IPA as clinically integrated. Here they are:

Systems to establish quality and utilization goals

Evaluation of individuals' and the network's performance as they relate to these goals Case management, some requirements for preauthorization, and review of inpatient stays

Investment in an information system

Comparison of network performance with cost and quality benchmarks

Monitoring of patient satisfaction

Detailed service reports provided to a payer

Presence of a medical director and support staff

Physician involvement in development of standards and protocols

Retention of an agent to negotiate contracts

No exchange of information about physician fees for non-network patients

No physician agreement on fees for patients outside network contracts

Physicians permitted to practice outside the IPA

The number of IPA physicians in any one specialty constitutes no more than 35 percent of the market's total number of physicians in that specialty

The problem with this example, however, is that it's idealized. …