Integrated Delivery Networks

Bruce Feinberg, DO: All right, panelists, we’re going to move to our second topic, and that’s integrated delivery networks and their impact on healthcare delivery, specifically in oncology care. It’s interesting that I came into the industry, the side of medicine, 7 or 8 years ago. I didn’t know the term integrated delivery network. It’s actually remarkable how many acronyms I didn’t know and how many confused me. Who knew that TA was not temporal arteritis, but rather it was treatment area. I really struggled to see why they wanted to invest so much money in it. But nonetheless, as I’ve gotten to learn all the acronyms, IDN is a big one. I don’t know when hospitals became IDNs. I don’t know historically, but we talked a lot about consolidation.

To me, of what has happened in the past 2 decades of consolidation healthcare, a lot of it has been to take these hospitals and make them integrated delivery networks. I’d like to begin this segment by really allowing all the viewers to get a better handle on your perspectives regarding, When did hospitals become IDNs? How do you define the IDN movement of today?

Mark S. Soberman, MD, MBA, FACS: Obviously—I think we alluded to this a little in the previous discussion—hospitals have realized that they are not islands that provide inpatient care and they are now distributive. They are at least currently the anchor, but perhaps they will ultimately not be the anchor of a distributive healthcare network that provides care across an entire continuum: ambulatory, inpatient, chronic care management, and all the things that are happening. Obviously, the acquisition of physician groups and multispecialty practices has been a big part of that transition to the IDN. Quite frankly, I think the other driver is that although we’re in the early phase of this and cancer oncology care has been at the forefront of this, the idea of multidisciplinary care is organized around the patient’s medical condition as opposed to the specialty of the individual practitioner. Mike, you alluded to this earlier a little bit.

I think that oncology has been the poster child for this. Look at some organizations like the Cleveland Clinic and others that are starting to organize care across the entire continuum around specific medical conditions. There are the Cardiovascular Institute, the Gastrointestinal Institute, and physicians coalescing around the patient. I think we as a system are starting to understand that patients don’t come to us with a diagnosis of surgery or medical oncology or radiation oncology. They have a disease, and we need to figure out how to treat it. The IDN is a platform with which to do that.

Bruce Feinberg, DO: Dana, are there components that are required? To be an IDN, do you have to have a hospital? Do you have to have a provider network? Are there pieces that make it? Is just any hospital, if it’s big enough, an IDN? What makes it integrative? What are those services that are required?

Dana Macher: I think that there are many services that are required. It goes to Mike’s earlier point about having some breadth. For instance, a lot of them are bringing in and acquiring home infusion services as part of the integrated network. That makes sense to them because they are better able to coordinate that care. They’re also able to keep that patient within the system if home infusion is the best thing for that patient. I think a lot of it is being able to retain that patient in general and offer what is best for them.

Bruce Feinberg, DO: Mike, thoughts on this?

Michael Kolodziej, MD: I think with the exception of surgical specialty hospitals, virtually every hospital that we might encounter would fancy themselves to be an IDN. This is really happening insidiously over the years. All of us know that hospital systems have bought nursing homes. Hospital systems have bought physician practices. Typically, it’s procedurally oriented. They’re very lucrative physician practices or oncology practices where they have a lovely revenue center that comes along with the acquisition of practice.

Bruce Feinberg, DO: Orthopedics.

Michael Kolodziej, MD: Orthopedics is another great example. I think this has happened in both urban and rural settings. I think it’s happened nationwide. I think the reason to do it, which was to diversify and capture more of the patient dollar, has changed a little bit. Now I think we’re in a universe where being more efficient in controlling cost may put you in a better negotiating position with a payer, and you cannot control what you do not own. As participants in the Oncology Care Model have unfortunately learned, postacute care costs a lot of money. Nobody asked the oncologist which nursing home to send the patient to because the hospitals don’t care what the model says about what nursing home to use.

But the hospitals have caught on to this. The reason for their existence is changing because of risk and managing cost and managing population. I think it’s a natural evolution from a true fee-for-service model to a different model.

Mark S. Soberman, MD, MBA, FACS: To your point, you can’t enter into an ACO [accountable care organization] agreement. Our health system is a Medicare Shared Savings ACO; we’re currently in 1-sided risk, and we’ve done well. But we have to have primary care specialties, all the sites of care. We have to partner with community physicians as well.

Bruce Feinberg, DO: But often those are partnerships not owned.

Mark S. Soberman, MD, MBA, FACS: We own a lot, and we also partner with those that we do not own. But what is interesting is that 1-sided risk is going to go away, and everybody is going to have to take 2-sided risk. If you don’t have a network that’s diverse, you can’t do it.

Michael Kolodziej, MD: No, that’s right.

Bruce Feinberg, DO: It’s interesting. We talked about all the different drivers for the IDN movement, and yet one of the outcomes of the IDN movement has been hospital closures. We’re averaging right now, according to an article published yesterday, 30 a year. Where those closures are most likely to take place are in rural areas. We’re starting to get some major gaps in coverage.

It’s interesting when we think about roles and responsibilities and the original specific design of our healthcare system and then the nature of what’s happening as a result of these drivers, many of which are financial. Some of it may often relate to performance metrics where populations do better because we know the lower socioeconomic populations also have usually lower healthcare outcomes and greater reliance on certain healthcare services because they lack either financial or social service support. But it raises interesting questions that are very philosophical but also pragmatic: How does our healthcare system address core responsibility in dealing with the healthcare population?