Clinical integration is a new model for health care delivery. The model promotes collaboration among a community’s independent providers to furnish high quality care in a more efficient manner. Physicians, hospitals, and other providers share responsibility for, and information about, patients as they move from one setting to another over the entire course of their care.
Working together, clinically integrated providers develop and implement evidence-based clinical protocols, focusing on delivery of preventive care and coordinated management of high-cost, high risk patients. Utilizing shared information technology, these providers conduct ongoing clinical care reviews to identify opportunities for improvement and ensure adherence to protocols.
While the antitrust laws generally prohibit joint contract negotiations among independent providers, those laws permit clinically integrated providers to engage in collective negotiations with health plans. Working together, these providers can more effectively compete for payer contracts because they demonstrate high quality and greater efficiency in care delivery.
A clinically integrated network is the infrastructure needed to support clinical integration among a community’s independent providers. The network develops a governance structure through which these providers come together to decide on protocol development and implementation, performance measurement and enforcement, and formulas for rewarding performance.
Other network activities include, for example, identifying, implementing, and maintaining supportive technologies (including data analytics); analyzing care processes to identify efficiencies; encouraging patient engagement; negotiating pay-for-performance payer contracts; and distributing incentive payments to members.
Clinical integration involves both private practice and physicians in the Wellvana Medical Group who join together in an organization or network that allows them to:
Identify and adopt best practices for the treatment of patients
Develop systems to monitor performance against adopted metrics
Collaborate with Wellvana hospitals to improve processes of care
Enter into contractual arrangements with health plans that financially recognize physicians’ efforts to improve quality and efficiency
An effective clinical integration network contains initiatives that involve all physicians committed to a common set of clinical goals. These goals are likely to improve the health of a community, provide measureable results in quality improvement, efficiency of care and patient safety. Measurable results can also be used to compare physician performance which results in quality improvement.
Community physicians will maintain their own practice. Membership in the CIN does not imply employment by Wellvana and does not impact practice identity, operations or staff. Wellvana CIN membership does require a commitment in terms of time, accountability, and compliance with the CIN’s clinical initiatives.
Data will be downloaded to a secure database. Access to that database will be restricted to the CIN leadership and the CIN Board will determine how the data is utilized.
A clear set of goals for cost savings and quality improvement that can reasonably be achieved through integrating the network providers’ clinical practices and modifying their practice patterns;
Selectively choosing to recruit and retain network providers who are likely to further the network’s goals;
Significant investment of capital, both monetary and human, in the network infrastructure and capability necessary to achieve the goals;
Electronic clinical records systems to facilitate care coordination, reduce duplication, and enhance efficiency;
Development of comprehensive evidence-based clinical guidelines designed to modify practice patterns and achieve the goals;
Rigorous guideline implementation, performance measurement, and compliance mechanisms, to monitor and control how care is delivered; and
In-network referrals to participating specialists, all of whom have committed to follow the network’s clinical guidelines.
Yes. Wellvana and its physician members have been actively engaged in the process of exploring a clinically integrated physician network. The Wellvana CIN will be governed by an operating committee led by physicians and will operate for the explicit purpose of developing and implementing a clinically integrated network. The Wellvana CIN will negotiate single signature payer arrangements with health plans and will share in the savings generated by improving quality and reducing costs.
Physicians have numerous and overlapping motivations for joining together in clinically integrated networks including the following:
Enhancing the quality of care provided to patients
Allowing physicians and hospitals to market themselves on the basis of higher quality
Legitimately negotiating with payers as a network
Access to technological and quality improvement
Infrastructure that enables evaluation of physician performance
Physicians and health systems nationwide are developing clinical integration programs because they believe in the value they create for the patient, provider and payer. Clinical integration allows physicians and health systems to:
Demonstrate their quality to current and future patients
Choose the clinical measures they will be evaluated against
Enhance revenue through better management of patients
Gather collective support for necessary infrastructure
Engage in group contracting
No, one of the advantages of a CIN is the ability to market and negotiate on behalf of the entire network to derive reimbursements that recognize quality and scope of the network. Additionally, it is anticipated that the CIN will negotiate pay for performance elements in addition to the fee-for-service base payment rate. Such performance incentives are not currently available to physicians.
These are critical questions to be addressed through the planning process. The CIN’s governance structure must further its members’ common goals while protecting their individual interests. This is achieved through the selection of governing board members, balancing voting rights among participants, reserving certain fundamental decisions to the respective parties, delegating organizational functions through carefully drafted committee charters, and other organizational processes.
Before deciding on a particular structure, however, there should be consensus around common goals, i.e., identification of the functions the CIN will perform. Stated another way, the form the CIN takes should follow from the functions it will perform, not vice versa.
Physicians will be asked to agree to the following:
Criteria-based selection of providers
Accept an appropriate level of risk
Quality and cost improvement initiatives including required data sharing
Accountability for a shared population
Yes. Participation in the quality and care management initiatives of the Wellvana CIN will require focused time and attention from physicians to achieve the goals of the CIN. The CIN will not supersede a physician’s clinical judgment in the practice of medicine. However, the CIN will develop clinical guidelines and participation in quality and utilization efforts. CIN physicians will be eligible to obtain financial rewards for their additional efforts.
An ambulatory EMR is not a prerequisite for the development of clinical integration. While a common EMR across all participating physician practices can certainly accelerate and strengthen a clinical integration program, many successful models nationwide do not depend on an ambulatory EMR system for data on physician performance. Sharing claims data and performance metrics will be necessary to enable the success of the CIN.
Typically, a CIN develops its initial set of protocols around delivery of preventive care and management of patients with chronic diseases (e.g., diabetes, COPD, asthma, heart failure). CINs have utilized well-recognized quality standards as a basis for protocol development including, for example, National Quality Forum-endorsed standards. Other sources include CMS’ Physician Quality Reporting System measures, the Medicare Shared Savings Program performance standards, and Stage 1 and 2 meaningful use quality reporting requirements
A CIN can employ technological solutions in several ways to advance its goal of improved population health:
First, technology can assist a physician in adhering to clinical protocols, such as tracking whether a patient has received certain preventive services.
Second, reporting on quality measures to the CIN (or to payers directly) may be accomplished using IT solutions.
Third, data analytics can identify those patients for whom certain interventions are appropriate, thus allowing providers to manage those patients more effectively.
Fourth, technology can assist the CIN in tracking care costs to identify opportunities for improvement.
Fifth, electronic health information exchange permits CIN members to effectively coordinate patient care (especially for high-cost, high-risk patients), thus improving outcomes and reducing costs.
Sixth, patient and family member access to electronic records enables them to be more active and
Since 1996, the FTC has been very consistent in its definition of clinical integration as well as the analytical framework it applies when evaluating clinical integration among a network of independent physicians. As defined by the FTC, a “qualified clinically integrated arrangement” is an arrangement to provide physician services in which: 1. All physicians who participate in the arrangement participate in active and ongoing programs of the arrangement to evaluate and modify the practice patterns of, and create a high degree of interdependence and cooperation among, these physicians, in order to control the costs and ensure the quality of services provided through the arrangement, and 2. any agreement concerning price or other terms or conditions of dealing entered into by or within the arrangement is reasonably necessary to obtain significant efficiencies through the joint arrangement.
The FTC has also indicated on numerous occasions that clinical integration programs may include:
Establishing mechanisms to monitor and control utilization of healthcare services that are designed to control costs and assure quality of care;
Selectively choosing network physicians who are likely to further these efficiency objectives; and
The significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies. (Statements of Antitrust Enforcement Policy in Healthcare by the FTC and the U.S. Department of Justice, Statement 8, August 1996).
First, adherence to CIN-approved clinical protocols and sharing of patient data eliminates unnecessary and duplicative care. A greater emphasis on preventive services saves money by avoiding more expensive care down the line.
Second, a physician participating in a CIN has access to the network’s care coordination services for his or her patients. This includes transitional care management as well as patient navigator programs.
A transitional care management program focuses on patients discharged from institutional care (hospital, skilled nursing facility) to ensure they successfully transition back into their home setting. These programs have proven successful in reducing hospital readmissions and costly emergency room visits.
A patient navigator program focuses on a small number of high risk, high cost patients. Research indicates that in most communities, five percent of the patients generate fifty percent of the cost. By aggressively supporting these patients through care coordination and treatment regime adherence, patient navigators often can reduce these costs by one-third.
One of the key tasks for Wellvana leadership is to reach consensus regarding the range of services to be provided. The following is a non-exclusive list of services a CIN might provide for its members.
Keep in mind the CIN does not necessarily have to provide all services directly; the CIN may contract with third parties (including, for example, the hospital) for specific services. Also, in the future, the CIN may contract to provide services to third parties. This may be a way for the CIN to generate revenue to support its operations.
Operate disease registries/data analytics
Implement evidence-based medicine practices/population health improvement strategies
Identify and develop practice protocols (e.g., align with payer-required measures)
Support protocol implementation and adherence (e.g., education, technology solutions)
Monitor protocol compliance (reporting on quality measures
Implement corrective action for protocol non-compliance
Establish chronic disease management/patient navigator program
Develop transitional care management program (based on new Medicare Physician Fee
Schedule payment for post-discharge transitional care management)
Implement medication therapy management program
Provide Physician Quality Reporting System support for physician members (e.g. education, abstracting, technology solutions)
Provide CMS Maintenance of Certification program support for physician members (e.g., CME opportunities, practice assessment, attestations)
Develop patient education and engagement strategies and tools (e.g., shared decision-making)
Explore clinical co-management arrangements and/or gain-sharing opportunities (hospital service line quality and efficiency improvement programs with financial rewards to physicians if program meets specified targets)
Develop bundled payments for specific episodes of care (e.g., surgical procedures, maternity)
Develop Centers of Excellence (by service line)
Participate in Medicare Shared Savings Program (accountable care organization)
Pursue preferred network contracts with private payers
Pursue shared savings and/or global budget contracts with private payers (including employers)
Develop and market health plan (e.g., hospital employee health plan, Medicare Advantage)
Provide EHR/meaningful use technical support for physician members
Furnish support for primary care providers in implementing patient-centered medical home model
Form or contract with group purchasing organization
Perform back-office functions for physician offices (e.g., coding, billing, collecting, accounts payable)
Provide support for ICD-10 transition and compliance
Provide HIPAA Privacy and Security Rule compliance support
The term clinically integrated network dates back to the mid-1990s, when the Department of Justice and the Federal Trade Commission first acknowledged independent providers working together to improve quality and efficiency could engage in joint payer negotiations.
The term accountable care organization was first used about a decade later in reference to a group of providers that assumes responsibility to provide care for an assigned patient population. Typically, an ACO bears some financial risk associated with providing such care.
Generally speaking, an ACO is a more formal arrangement, structured to satisfy specific payer requirements. For example, only an ACO that meets certain regulatory requirements is eligible to participate in the Medicare Shared Savings Program. A CIN may elect to form an ACO for purposes of contracting with a particular payer. That decision, however, may be deferred until the CIN is fully operational.
The federal Anti-Kickback Statute, the Stark Law, and the Civil Monetary Penalties Act (collectively referred to as the fraud and abuse laws) place restrictions on relationships among health care providers. For example, any financial relationship between providers must be based on fair market value for the goods or services provided.
Any financial relationship created as part of the CIN will have to be structured in a manner to comply with the fraud and abuse laws. The CIN does not provide any special protection from the civil and criminal penalties associated with violations of these laws.
An ACO that participates in the MSSP and meets certain quality standards is eligible to receive a portion of any savings generated through improved efficiencies in care delivery. CMS measures these savings based on its annual expenditure per beneficiary assigned to the ACO as compared to a historical benchmark. Beneficiaries are assigned to an ACO based on their primary care physician.
In addition to eligibility for shared savings, an ACO participating in the MSSP enjoys waivers from the Anti-Kickback Statute, the Stark Law, and the prohibitions on gainsharing and beneficiary inducements, all of which now serve as barriers to provider collaboration. (Groups of providers organizing for purposes of participating in the MSSP also benefit from these waivers.) As a result, ACO participants can enter into financial arrangements otherwise prohibited by law.
If the CIN elects to pursue participation in the Medicare Shared Savings program as an ACO, it would enjoy significantly greater flexibility in structuring relationships among its member providers.
Currently, there are more than 250 ACOs participating in the MSSP, covering up to 4 million Medicare beneficiaries.
Under a pay-for-performance contract (often referred to as a P4P contract), an individual provider continues to submit claims and received fee-for-service reimbursement. If the provider achieves a certain goal specified in the contract, the provider receives an additional incentive payment. A P4P contract may provide for a penalty if a provider fails to meet a specified target. The Medicare Physician Quality Reporting System (“PQRS”) is an example of a P4P program. Under PQRS, a physician will receive a 0.5 percent bonus payment if he or she submits a report on specified quality measures in 2013. If, however, a physician does not submit such a report in 2013, that physician will be penalized 1.5 percent on Medicare payments in 2015. Many commercial payers are looking to include P4P provisions in their contracts with individual providers. Generally speaking, a CIN can negotiate more favorable P4P terms. Also, a CIN supports an infrastructure that enables its members to achieve P4P measures. Under a shared savings program, a network of providers is eligible to receive a portion of a payer’s savings generated by improved quality and efficiency. This is accomplished through a multi-step process:
The payer assigns a specific patient population to the CIN, usually based on the patients’ primary care provider.
Providers in the CIN continue to receive fee-for-service reimbursement for all services, including services for patients in the assigned population.
The payer calculates a benchmark rate based on the payer’s historical cost of providing care for that population.
At the end of the year, the payer calculates its actual cost of providing care for the patient population. (This includes the costs of care furnished by providers not included in the CIN. Patients in the assigned population are not limited to providers in the CIN).
If the actual costs of care are less than the benchmark and if specified quality measures are met, the CIN will receive a portion of the savings. If those measures are not met, the payer will not share the savings with the CIN.
Under “two-sided” shared savings programs, the CIN is liable for a portion of the difference if the actual costs of care exceed the benchmark.
The CIN is responsible for deciding how the shared savings (or losses) are to be distributed among its members. Typically, a portion of any shared savings payment is retained by the CIN to pay its expenses.