TABLE 4.

Barriers to Economic and Clinical Integration

Category of Barrier	Specific Illustrations
Physicians' internal issues
	Physicians' dismissal of clinical integration
	Disruption caused by installation of clinical integration
	Physicians' decreasing time spent in hospital
	Shortage of large physicians' groups aligned with hospitals
	Physicians' conflicts of interest and lack of transparency
	Percentage of medical staff in one- or two-person practices
	Specialists' turf issues
	Cultural divide between physicians and hospitals
	Aging of medical staff
	Lack of physician leadership
	Lack of trust in hospital executives
	Lack of compensation beyond productivity
Hospital's resources
	Hospital's financial condition
	Hospital's capacity constraints
	Lack of clinical information systems
	Lack of “system-ness” in hospital systems
	Hospital's desire to avoid dependence on one IT vendor
	Geographic dispersion
	Hospital's focus on other strategic initiatives
Market competition
	Low CON restrictions on ASCs in state
	Penetration of nonhospital, physician-centric firms/chains
	Hospital's market share and hospital market HHI
	Hospital's payer mix and payer market HHI
Physicians' external market
	Fragmentation of physicians
	Dominance of independent physicians
	Physicians' reimbursement trends and pressures
	Physicians' efforts to increase their incomes
	Changes in economics of physicians' practices
	Changes in work versus physicians' lifestyle preferences
	Rise in percentage of physicians working part-time
	Physicians' rising expectations
	Shortages of physicians in cardiology, orthopedics, neurosurgery
Regulatory pressure
	FTC and DOJ investigations of physician-hospital alliances
	Rules of engagement: Anti-kickback, Safe Harbor, Stark
	OIG and IRS rulings
	Corporate practice of medicine statutes (five states)
Reimbursement pressure
	Changes in Medicare reimbursement: ASC fees, physicians' fee schedules
Environmental trends
	Technological advances making ambulatory care attractive
	Market malpractice rates