In Pursuit of Clinical Integration: Know the Parts and How They Fit

David O. Scamurra,MD, FCAP, is president of Eastern Great Lakes Pathology, a 14-member clinical and anatomic pathology group in western New York. The pathologists of Eastern Great Lakes are also members of Catholic Medical Partners (CMP), an integrated delivery system made up of Catholic Health, which has four hospitals in the Buffalo, New York, region and 950 independent physicians who care for patients served by those hospitals.

CMP negotiates and manages all managed care contracts for its accountable care organization (ACO), which the Centers for Medicare & Medicaid Services (CMS) selected as one of 27 nationwide invited to participate in its Shared Savings Program. In the mid-1990s, when Catholic Health and the Catholic Independent Physician Association (CIPA) formed CMP, Dr. Scamurra (who had been among CIPA's founding board members) was director of central lab services for Catholic Health and also chairman of the board for CIPA.

"Right from the beginning, the idea was that we wanted to create pay-for performance and do evidence-based medicine," Dr. Scamurra says. "That's why we formed it. It was an alliance between the physicians and the hospitals to line up incentives and negotiate contracts that had money in them above and beyond the fee-for-service (FFS) global medical budget—money that would allow us to pay physicians to change behavior. That's really what an ACO is, but we did it 15 years ago."

Action/Solution

At the time, Dr. Scamurra says, pathologists in the Buffalo region were being paid about 60% of the national Medicare average, primary care physicians about 85%, and specialists a bit more. There were intense discussions around bringing greater equity to physician compensation. In the end, he said, "We convinced people that we were going to put the initial incentive dollars into those specialties and primary cares that were below a certain level of Medicare, to bring them up to a Medicare-competitive rate. There was leadership from CIPA and the doctors in the community and the hospitals, and we talked it through."

Then, as now, Dr. Scamurra says, many physicians were not aware of barriers that pathologists faced. Payment for Medicare Part A hospital services was the hot issue at the time, and that concern remains. Today's more prominent worry, though, is a recent indication by the ACO that language in its shared revenue program contract with CMS appears to disallow incentive payments for "outcomes consistently achieved, as well as for basic competency of practice." If such a limitation persists, he says, much of what pathologists contribute in an integrated delivery system might not be reimbursed.

In his experience, Dr. Scamurra says, when pathologists educate their peers about what goes into quality clinical pathology services, their value is quickly acknowledged. Their intellectual involvement in the practice of medicine is evident in countless ways. However, Dr. Scamurra says, pathologists should not be criticized for not doing what they cannot do.

For example, a pathologist can ask the IT department to post a warning on the computerized physician order entry screen suggesting that a given test may not be needed and offering a pathology consult, Dr. Scamurra says. He or she can suggest to the ACO that clinicians be incented for limiting their orders for certain tests to certain circumstances. But the pathologist cannot and should not overrule another physician's patient care decision.

"You have to have a very clear view of what an integrated delivery system is and how the different parts fit when you start to think about how you want to incent people to do things," Dr. Scamurra says.

"In my view, you don't really want specialists to cut their costs. What you really want a specialist to do is develop guidelines that they will stick to and develop purchasing habits that are rational for ancillary things like implants. Guidelines that they will stick to and whose outcomes you can measure, because if you do that, the cost will take care of itself."

Summary

CMP continues to pursue accelerated clinical integration that incentivizes high-quality care, optimal patient outcomes, efficiency, and economy while sustaining financial viability and equitable physician compensation. There is no known endpoint to this endeavor, Dr. Scamurra says; no reason to think that the blueprint for a perfect health care delivery system will be wrapped up in a tidy package anytime soon. But the goal is a challenge of good purpose and the bright spots continue to multiply. CMP is one of those.