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GE Healthcare Camden Group Insights Blog

Population Health 2.0: Activate Your Strategy Through a PHSO

Posted by Matthew Smith on Aug 18, 2016 11:12:27 AM

By Graham Brown, MPH, CRC, Vice President, GE Healthcare Camden Group

With the transition to value-based payment, medical practices are aligning with Accountable Care Organizations (“ACOs”) and clinically integrated networks (“CINs”). These enabling business structures, with the new payment models, require a new level of support to medical practices. A true Population Health Support Organization (“PHSO”) is the perfect fit in a dynamically evolving delivery landscape.

Strategically, a PHSO aims to integrate providers, hospitals, payers, and services across the continuum of patient care. The interoperability between each of the entities reduces fragmented patient care and serves as the bridge between healthcare silos. A PHSO is the key platform to help providers transition into the new world of medicine by providing infrastructure for physicians to reshape and drive patient-centered care and engagement via efficient management of patient populations. It is a sound structure for those starting and maintaining a CIN, or simply for those managing medical practices that are evolving to meet the demands of the future delivery system. Much like Management Service Organizations (“MSOs”) of the past, a well-designed PHSO may also support physicians who wish to remain and thrive in private practice but still collaborate with other providers across the continuum.

Setting the Objectives

The objectives of a PHSO are three-fold: support physicians in sound financial management, quality improvement, and infrastructure needed for population health. These include moving the needle on quality measures and outcome performance, controlling total cost of care, and providing improved patient access to medical care. The goal is to improve patient loyalty and experience, ultimately keeping patients in the organized system of care. The PHSO also acts as an aggregator of key patient and administrative data; so it may become the conduit for the transfer of knowledge critical to success in managing the health of populations.

PHSO vs. MSO

So how is the PHSO of tomorrow different from the MSO of the past? The PHSO is a vehicle to connect all the dots for the transformation from the old fee-for-service to the new value-based payment models. There are many benefits to organizing and operating a PHSO to support physicians’ transition to value-based care delivery, including:

  • Integrating physicians with the organized delivery system of care, which supports ACO and CIN initiatives
  • Providing a contracting vehicle that allows and supports providers to assume risk and manage it effectively.
  • Coordinating the care management services across the continuum and managing transitions of care from one setting to another
  • Enhancing system interoperability to exchange and share data among the providers to support care delivery
  • Improving financial performance and managing the complexities of practice management
  • Ensuring compliance with CMS programs, such as MACRA, and avoiding payment reductions
  • Supporting consumerism by creating a unified brand focused on consumer experience and loyalty
  • Managing the revenue cycle and coding processes (i.e., diagnosis coding, chronic care management requirements, Hierarchical Condition Categories ("HCC")/Risk Adjustment Factor ("RAF) to support value-based contracts
  • Providing education to physicians—both employed and independent—on topics such as industry trends, leadership, care redesign, etc.

Whether physicians are employed or independent, the PHSO can support them equally while providing a vehicle for improved operational and financial performance.  

Where to Begin

Systems should begin by assessing their employed medical groups and conducting outreach to independent, affiliated medical groups to determine needs, timing of the value-based transition, and identify the gaps. These become the starting points for core PHSO services. An existing CIN, ACO, or MSO could evolve to become the PHSO. The key to success is either designing a new or adapting an existing organization to fill the identified gaps of support services needed to be successful under changing reimbursement and care delivery models. Lastly, the PHSO can be used to gain new relationships while strengthening existing relationships with physicians. These partnerships will allow the collective organizations to ultimately improve the health of the populations they manage.

The healthcare delivery system and corresponding reimbursement models are undergoing significant change…which is unlikely to slow down. The old ways to practice medicine will no longer work in the world of a value-based payment system. A transformation of current practice structure, business strategy, and partnerships along the continuum of care will play key roles for success in the new healthcare world.

 Population Health Support Organizations, PHSO


BrownG-470185-edited.jpgMr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at g.brown@ge.com.

 

Topics: ACO, CIN, Graham Brown, Population Health Support Organization, PHSO

Strength In Numbers: Super Clinically Integrated Networks Built to Improve Healthcare Value

Posted by Matthew Smith on Mar 22, 2016 2:27:39 PM

Graham A. Brown, MPH, CRC, Vice President, and Marc Mertz, MHA, FACMPE, Vice President, GE Healthcare Camden Group

As organizations assess their capabilities, resources, and infrastructure to succeed in evolving value-based reimbursement structures, many health systems have begun to partner with other health systems in a manner that allows organizational independence but fosters collaboration in areas where synergies may exist, specifically around population health management.

The creation of super clinically integrated networks ("SCINs") reflects this trend. For some, these SCINs are merely a stepping stone to full integration or merger, but to most, these affiliations are viewed as a vehicle to strengthen each of the independent members by collectively joining forces to improve healthcare value.

These SCINs could have significant strategic potential if they are able to organize appropriately, prioritize initiatives, and advance to the level of jointly assuming risk, developing effective care models, and positioning the members as an attractive option to healthcare purchasers.

Often, SCINs embark on relatively low risk activities at the outset such as optimizing the supply chain, sharing services and overhead, sharing clinical knowledge around best practices, and improving patient access (particularly when organizations are in different markets).

While these may be reasonable starting points that help to garner trust and build momentum, they will not be solid long-term strategies on their own to support sustainability of the SCIN or lead to return on investment for its members.

Establishing goals and objectives of the SCIN at the outset with cohesive strategy formulation and buy-in, as well as ensuring that it is properly resourced, will be integral to their success.

As mentioned, most SCINs that have been formed have a goal of developing joint population health management infrastructure. Defining exactly what this means and responsibilities of the SCIN versus responsibilities of each individual member is a key initial step.

Certainly, there is extensive cost associated with developing the proper infrastructure to support population health. Thus, the economic opportunities to the SCIN should be evident when compared to resourcing population health initiatives as individual organizations.

Ultimately, as the population health infrastructure is built and care model effectuated, there are many opportunities to better manage care and impact overall value. Many SCINs endeavor to offer an attractive, efficient delivery network to self-funded employers via direct to employer contracting; and this activity often begins with their own collective employee health benefits programs. More advanced SCINs progress to joint payer contracting but will need to have achieved clinical and/or financial integration to an acceptable level.

Shifting of financial risk from major payers to the SCIN through a plan-to-plan type arrangement or global capitation are other alternatives as the SCIN evolves and is better equipped to manage risk. Further, the individual exchange marketplaces and Small Business Health Options Program (“SHOP”) allow these advanced delivery networks to access individuals and small groups in an efficient manner and compete more quickly with larger carriers.

Depending on the overall goals, objectives, market characteristics, and current capabilities of each individual member and the SCIN, a provider sponsored health plan may be another opportunity to consider. Between 2012 and 2015, 54 percent of the new Medicare Advantage plan entrants were provider owned.

There is great risk in starting a health plan, but sharing this risk across organizations in the SCIN could be a mechanism to diffuse risk and share collective resources. Additionally, the mere scale in size of the SCIN provides a larger pool of lives than any individual system would have on its own. While the task seem to daunting, particularly at a time when the healthcare system is changing rapidly, embarking on these initiatives collectively may prove to be the best strategy.

There is significant opportunity for super clinical integrated networks to chart their own path and truly transform the delivery system in a positive manner. However, coordinating efforts across multiple large organizations that remain independent is not without its challenges.

Starting with the basics is a reasonable first step so long as there is a well thought out strategy and plan to more fully develop the organization to its potential.

Each individual organization will have its separate priorities. Determining how the SCIN moves forward as “one” while supporting the independence and priorities of the individual organizations will be key to their success.

An effectively designed governance structure of the SCIN that includes the chief executive officer of each member, along with one other key leadership position, is recommended. This will allow nimbleness of the SCIN in decision-making, but will also foster effective communication and alignment of strategies.

Those organizations that can pull it all together could easily set themselves apart and have significant strategic advantage in their respective market(s). Developing a detailed strategic framework for the SCIN that all parties support and holding each other accountable will serve as a foundation of success for these organizations.


BrownG.jpgMr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at g.brown@ge.com.

 

MertzM.jpgMr. Mertz is a vice president with GE Healthcare Camden Group and has 18 years of healthcare management experience. He has 15 years of experience in medical group development and management, physician-hospital alignment strategies, physician practice operational improvement, practice mergers and acquisitions, medical group governance and organizational design, clinical integration, and physician compensation plan design. He may be reached at marc.mertz@ge.com.    

 

This article was originally published by Modern Healthcare Executive, November 27, 2015

Topics: CIN, Clinically Integrated Networks, Clinically Integrated Network, Marc Mertz, Graham Brown, Super CIN

PDF Download: The New Paradigm of Patient Access

Posted by Matthew Smith on Mar 9, 2016 2:18:02 PM

In order for new clinically integrated networks (CINs) to achieve success, they must increase ways for patients to access care. To accomplish this, CINs and hospital leaders must embrace non-traditional access points that patients use to enter their systems.

Patients may choose to access the system through retail clinics because it is easy and convenient, and they are able to get what they need quickly. Those components, successfully integrated into a CIN, can serve as significant access points into a network.

In instances when CINs identify outside providers where their patients are going to get care, CINs should establish a contractual relationship with the provider. Such new access points come with their own challenges, including difficulty with sharing patient information and with communication. 

But hospitals need to think about the issue of access beyond patient visits to the emergency department, primary care, or even retail clinics. More CINs are focusing on access points to help keep patients in their networks. When analytics indicate the patient outmigration rate (patients going outside the network—often referred to as "leakage") is more than 5 to 10 percent, the providers must find ways to keep more patients in the network.

Increasing access can also turn into a selling point for the CIN to increase volume by touting its ability to provide convenient care. Selling the CIN to patients is particularly important in the era of high-deductible health plans, where patients actively select providers based on price and quality. 

This PDF download from GE Healthcare Camden Group provides insight surrounding:

  • How people rate access
  • What consumers want (old vs. new models)
  • Expectations surrounding access redesign
  • Consumer trust statistics
  • The new paradigm of patient access
  • Objectives of "best in class" patient access
  • Creating loyal patients for life
  • The continuum of organized care

Patient Access, Healthcare Networks

Topics: Patient Care, CIN, Patient Access, Continuum of Care

Super Clinically Integrated Networks Offer Unique Opportunities

Posted by Matthew Smith on Dec 8, 2015 2:09:45 PM

By Graham Brown, MPH, Vice President and Clinical Integration Practice Leader; Marc Mertz, MHA, FACMPE, Vice President and Physician Services Practice Leader, GE Healthcare Camden Group

As organizations assess their capabilities, resources, and infrastructure to succeed in evolving value-based reimbursement structures, many health systems have begun to partner with other health systems in a manner that allows organizational independence but fosters collaboration in areas where synergies may exist, specifically around population health management.

The creation of super clinically integrated networks ("SCINs") reflects this trend. For some, these SCINs are merely a stepping stone to full integration or merger, but to most, these affiliations are viewed as a vehicle to strengthen each of the independent members by collectively joining forces to improve healthcare value.

These SCINs could have significant strategic potential if they are able to organize appropriately, prioritize initiatives, and advance to the level of jointly assuming risk, developing effective care models, and positioning the members as an attractive option to healthcare purchasers.

Often, SCINs embark on relatively low risk activities at the outset such as optimizing the supply chain, sharing services and overhead, sharing clinical knowledge around best practices, and improving patient access (particularly when organizations are in different markets).

While these may be reasonable starting points that help to garner trust and build momentum, they will not be solid long-term strategies on their own to support sustainability of the SCIN or lead to return on investment for its members.

Establishing goals and objectives of the SCIN at the outset with cohesive strategy formulation and buy-in, as well as ensuring that it is properly resourced, will be integral to their success.

As mentioned, most SCINs that have been formed have a goal of developing joint population health management infrastructure. Defining exactly what this means and responsibilities of the SCIN versus responsibilities of each individual member is a key initial step.

Certainly, there is extensive cost associated with developing the proper infrastructure to support population health. Thus, the economic opportunities to the SCIN should be evident when compared to resourcing population health initiatives as individual organizations.

Ultimately, as the population health infrastructure is built and care model effectuated, there are many opportunities to better manage care and impact overall value. Many SCINs endeavor to offer an attractive, efficient delivery network to self-funded employers via direct to employer contracting; and this activity often begins with their own collective employee health benefits programs. More advanced SCINs progress to joint payer contracting but will need to have achieved clinical and/or financial integration to an acceptable level.

Shifting of financial risk from major payers to the SCIN through a plan-to-plan type arrangement or global capitation are other alternatives as the SCIN evolves and is better equipped to manage risk. Further, the individual exchange marketplaces and Small Business Health Options Program (“SHOP”) allow these advanced delivery networks to access individuals and small groups in an efficient manner and compete more quickly with larger carriers.

Depending on the overall goals, objectives, market characteristics, and current capabilities of each individual member and the SCIN, a provider sponsored health plan may be another opportunity to consider. Between 2012 and 2015, 54 percent of the new Medicare Advantage plan entrants were provider owned.

There is great risk in starting a health plan, but sharing this risk across organizations in the SCIN could be a mechanism to diffuse risk and share collective resources. Additionally, the mere scale in size of the SCIN provides a larger pool of lives than any individual system would have on its own. While the task seem to daunting, particularly at a time when the healthcare system is changing rapidly, embarking on these initiatives collectively may prove to be the best strategy.

There is significant opportunity for super clinical integrated networks to chart their own path and truly transform the delivery system in a positive manner. However, coordinating efforts across multiple large organizations that remain independent is not without its challenges.

Starting with the basics is a reasonable first step so long as there is a well thought out strategy and plan to more fully develop the organization to its potential.

Each individual organization will have its separate priorities. Determining how the SCIN moves forward as “one” while supporting the independence and priorities of the individual organizations will be key to their success.

An effectively designed governance structure of the SCIN that includes the chief executive officer of each member, along with one other key leadership position, is recommended. This will allow nimbleness of the SCIN in decision-making, but will also foster effective communication and alignment of strategies.

Those organizations that can pull it all together could easily set themselves apart and have significant strategic advantage in their respective market(s). Developing a detailed strategic framework for the SCIN that all parties support and holding each other accountable will serve as a foundation of success for these organizations.

This article was originally published by Modern Healthcare Executive, November 27, 2015


Mr. Brown is a vice president and clinical integration practice leader with GE Healthcare Camden Group and has over 25 years of experience in the areas of payer negotiations, program administration, and change management with healthcare provider, payer, government, and human service clients. He is an experienced leader in business planning and implementation for clinical integration and accountable care organization development across the U.S. He may be reached at gbrown@thecamdengroup.com or 585-512-3905.

 

mertz_headshot.pngMr. Mertz is a vice president with GE Healthcare Camden Group and has 18 years of healthcare management experience. He has 15 years of experience in medical group development and management, physician-hospital alignment strategies, physician practice operational improvement, practice mergers and acquisitions, medical group governance and organizational design, clinical integration, and physician compensation plan design. He may be reached at mmertz@thecamdengroup.com or 310-320-3990.    

 

Topics: CIN, Clinically Integrated Networks, Clinically Integrated Network, Marc Mertz, Graham Brown, Super CIN

Clinically Integrated Networks: Control Your Own Momentum

Posted by Matthew Smith on Nov 4, 2015 3:18:18 PM

By Daniel J. Marino, MBA, MHA, Executive Vice President, GE Healthcare Camden Group

Many hospital leaders fear the consequences of moving too fast. Last year, we talked to healthcare leaders nationwide about preparing for value-based payment. For many, the biggest fear is reducing their hospital revenues. What will happen if you transition care to lower-reimbursement ambulatory settings faster than you can grow value-based revenue? How do you increase volume to cover the shift in revenue from acute to ambulatory or post acute? Others are concerned about investment costs. Value-based care is new territory. That means many big upfront investments could end up being unnecessary.

Yet moving too slowly carries significant risks. Hospitals that fail to act now could soon lose market share to value-driven competitors. Lagging organizations will be forced to accept lower reimbursement on their remaining volume. They will not be in a position to accept value-based contracts from payers and will also be unable to offset utilization reductions with new revenue streams.

The ultimate penalty of inaction is that you will allow others to dictate your future. How do you find the right pace in transitioning your hospital to value-based care? The key to establishing the right momentum is to clinically integrate with other providers. A well calibrated clinical integration strategy will allow you to maximize value for your organization while minimizing risk.

The Basic Framework

Clinically Integrated Network, CINA clinically integrated network (“CIN”) is a group of provider organizations that come together to form an organized system of care. The network can include one or more hospitals, their employed physicians, independent community physicians, post acute providers, and other provider organizations. Member organizations remain independent but are aligned contractually. The entire network is physician-led and incorporates a multi-stakeholder governance body that oversees quality initiatives, financial goals, and other strategic issues.

Leading clinically integrated networks share a handful of key attributes and capabilities:

  • Physician-led organization with a focus on quality of care within a patient-centric model.
  • Care management capabilities to help improve quality and outcomes while reducing costs.
  • Clinical programs that optimize services for specific diseases and patient groups.
  • Advanced technology that is leveraged to improve electronic interoperability, standardize optimal care, and improve services at the point of care.
  • Population health capabilities that allow the CIN to aggregate data and manage the high-level factors that influence health outcomes.

The ultimate goal of a CIN is to secure value-based payment contracts. Providers receive financial rewards for superior quality and outcomes along with successfully managing cost trends. Value-based contracts align provider incentives with the needs of payers, employers, and patients.

Plan to Evolve

While clinical integration is complex and challenging, it is also a versatile strategy. CINs can develop infrastructure and capabilities step-by-step. Member organizations are able to assume risk at a steady pace while achieving powerful forward momentum.
Here is a simplified pathway for transitioning your organization from traditional volume-based payment to robust value-based care:

Phase 1: Lay the CIN foundation. Start by assembling the building blocks of a clinically integrated network. The risk is low, and potential gains are moderate. Key activities include establishing the appropriate governance structure and building the provider network. Establish the desired care model and the focus of quality programs with the ability to track outcomes. Network leaders should begin negotiating limited risk-based contracts that include provider quality and cost management incentives. Emphasize referral management strategies to keep patients within the CIN and the organized system of care. CINs that properly execute on the foundational elements and establish an organized system of care can create opportunities to increase revenue five to ten percent.

Phase 2: Develop a clinically integrated collaborative. As a CIN begins to experience success in creating an organized system of care, the next step is to assume additional risk, but target bigger rewards, by expanding the network regionally. Move strategically into other markets by partnering with providers that can benefit from your CIN’s provider network, technology, and care management infrastructure. At the same time, refine the network’s ability to manage costs, expand clinical guidelines, and support risk-based contracts. Hone capabilities for managing the entire enterprise through monitoring, analytics, and reporting. Explore opportunities to partner with payers in narrow-network health plans.

Phase 3: Transition to full-risk contracts. The most advanced CINs are creating provider-sponsored health plans that offer compelling revenue opportunities. This phase carries the most risk, but it can be mitigated substantially through strong care delivery, cost management, and utilization management capabilities. Networks at this stage can function as full-service ACOs, including organizations acting as provider sponsored health plans assuming full-risk contracts, similar to Geisinger Health System, Intermountain Healthcare, or Northshore Long Island Jewish Health System. Another strategic option is to offer insurance products directly to the market, either alone or in partnership with a payer. Direct employer contracting allows the CIN to “commoditize” its services, potentially increasing revenue 10 to 15 percent over traditional contracts. In order for this to be achieved, provider-sponsored health plans would need to be in place accompanied by a large provider network and organized systems of care. If “payer dependencies” are removed or limited, the healthcare spend decrease translates into revenue opportunities for the CIN.

Target Financial Opportunities to Mitigate Risk

One key to reducing the risk of value-based care is to take full advantage of its unique financial opportunities. Pay attention to four categories:

  • Infrastructure cost savings. Creating a strong shared administrative and care management infrastructure can allow a CIN to reduce per-member per-month (“PMPM”) costs 20 to 30 percent within 5 to 10 years.
  • Increased volume. Entering into narrow-network contracts with payers and employers can drive strong membership growth and patient volumes.
  • Increased domestic utilization. Minimizing patient leakage allows the CIN to maximize influence over care transitions and quality, a key to controlling costs.
  • Advanced care programs. Hospitals have the opportunity to develop advanced clinical programs and centers of excellence. Offering these programs to other network providers will increase revenue while further leveraging network effects.

The Starting Point

As you plan and launch a CIN, keep in mind one absolute necessity. Your organization must offer a strong value proposition to participating providers, payers, and patients.

For physicians, participation in your network must be an opportunity to improve patient care through access to care management, as well as clinical program and technology resources. Your CIN should also provide a management infrastructure that eases the challenges of practicing medicine today. It must facilitate care redesign to enhance care efficiency and patient focus, and optimize clinical resources.

For payers, your network must provide higher quality care, better patient outcomes, and better patient access, all while reducing the cost of care.

For patients, your network must provide access, affordability, and tools to facilitate care coordination and engagement.

A strong value proposition is key to finding the right “change momentum” for your organization. Focusing on providing value helps make sure you do not embrace change too quickly for your market. It also ensures your organization can maintain a steady forward pace by balancing appropriate risk with solid potential for clinical and financial gains.

Clinical Integration Networks, CIN, Daniel J. Marino


Mr. Marino is an Executive Vice President at GE Healthcare Camden Group with more than 25 years of experience in the healthcare field. Mr. Marino specializes in shaping strategic initiatives for healthcare organizations and senior healthcare leaders in key areas such as population health management, clinical integration, physician alignment, and health information technology. He may be reached at daniel.marino@ge.com.
 
 
 

Topics: Clinical Integration, CIN, Clinically Integrated Networks, Daniel J. Marino

New Download: Clinically Integrated Networks Overview--Attributes for Success

Posted by Matthew Smith on Jan 21, 2015 12:02:00 PM

Download, The Camden Group, Population Health, Clinically Integrated Networks, CIN, Clinical IntegrationHospitals and health systems face continued pressures to reduce healthcare costs and reimbursements (volume-based model). This necessitates a shift to accountable care and value-based reimbursement tied to performance of services.

This new download from Daniel J. Marino, Senior Vice President at The Camden Group, shares concepts tied to such a shift, including:

  • Challenges for health systems and providers
  • Enterprise transition to risk timing
  • Overview of clinically integrated networks
  • Attributes of clinically integrated care
  • Evolution of clinical integration
  • Risk vs. capabilities
  • Financial opportunities for clinically integrated networks
  • Building the clinical integration value proposition

To download this PDF, simply click the button below, complete the short form, and press the "Click for Download" button. Your file will appear and will be available for you to save to your device.

Clinically Integrated Networks, CIN, Clinical Integration, The Camden Group

Topics: Clinical Integration, CIN, Clinically Integrated Networks, Daniel J. Marino, The Camden Group

Clinically Integrated Networks: You Can’t Stop Change, But You Can Control Your Momentum

Posted by Matthew Smith on Jan 20, 2015 4:30:00 PM

By Daniel J. Marino, MBA, MHA
Senior Vice President, The Camden Group

Clinically Integrated Network, CINThe shift from volume to value in healthcare will pick up steam in 2015. The question for hospital leaders is not whether to embrace change, but how quickly.

Many hospital leaders fear the consequences of moving too fast. Last year, we talked to healthcare leaders nationwide about preparing for value-based payment. For many, the biggest fear is reducing their hospital revenues. What will happen if you transition care to lower-reimbursement ambulatory settings faster than you can grow value-based revenue? How do you increase volume to cover the shift in revenue from acute to ambulatory or post acute? Others are concerned about investment costs. Value-based care is new territory. That means many big upfront investments could end up being unnecessary.

Yet moving too slowly carries significant risks. Hospitals that fail to act now could soon lose market share to value-driven competitors. Lagging organizations will be forced to accept lower reimbursement on their remaining volume. They will not be in a position to accept value-based contracts from payers and will also be unable to offset utilization reductions with new revenue streams.

The ultimate penalty of inaction is that you will allow others to dictate your future.
How do you find the right pace in transitioning your hospital to value-based care? The key to establishing the right momentum is to clinically integrate with other providers. A well calibrated clinical integration strategy will allow you to maximize value for your organization while minimizing risk.

The Basic Framework

A clinically integrated network (“CIN”) is a group of provider organizations that come together to form an organized system of care. The network can include one or more hospitals, their employed physicians, independent community physicians, post acute providers, and other provider organizations. Member organizations remain independent but are aligned contractually. The entire network is physician-led and incorporates a multi-stakeholder governance body that oversees quality initiatives, financial goals, and other strategic issues.

Leading clinically integrated networks share a handful of key attributes and capabilities:

  • Physician-led organization with a focus on quality of care within a patient-centric model.
  • Care management capabilities to help improve quality and outcomes while reducing costs.
  • Clinical programs that optimize services for specific diseases and patient groups.
  • Advanced technology that is leveraged to improve electronic interoperability, standardize optimal care, and improve services at the point of care.
  • Population health capabilities that allow the CIN to aggregate data and manage the high-level factors that influence health outcomes.

The ultimate goal of a CIN is to secure value-based payment contracts. Providers receive financial rewards for superior quality and outcomes along with successfully managing cost trends. Value-based contracts align provider incentives with the needs of payers, employers, and patients.

Plan to Evolve

While clinical integration is complex and challenging, it is also a versatile strategy. CINs can develop infrastructure and capabilities step-by-step. Member organizations are able to assume risk at a steady pace while achieving powerful forward momentum.
Here is a simplified pathway for transitioning your organization from traditional volume-based payment to robust value-based care:

Phase 1: Lay the CIN foundation. Start by assembling the building blocks of a clinically integrated network. The risk is low, and potential gains are moderate. Key activities include establishing the appropriate governance structure and building the provider network. Establish the desired care model and the focus of quality programs with the ability to track outcomes. Network leaders should begin negotiating limited risk-based contracts that include provider quality and cost management incentives. Emphasize referral management strategies to keep patients within the CIN and the organized system of care. CINs that properly execute on the foundational elements and establish an organized system of care can create opportunities to increase revenue five to ten percent.

Phase 2: Develop a clinically integrated collaborative. As a CIN begins to experience success in creating an organized system of care, the next step is to assume additional risk, but target bigger rewards, by expanding the network regionally. Move strategically into other markets by partnering with providers that can benefit from your CIN’s provider network, technology, and care management infrastructure. At the same time, refine the network’s ability to manage costs, expand clinical guidelines, and support risk-based contracts. Hone capabilities for managing the entire enterprise through monitoring, analytics, and reporting. Explore opportunities to partner with payers in narrow-network health plans.

Phase 3: Transition to full-risk contracts. The most advanced CINs are creating provider-sponsored health plans that offer compelling revenue opportunities. This phase carries the most risk, but it can be mitigated substantially through strong care delivery, cost management, and utilization management capabilities. Networks at this stage can function as full-service ACOs, including organizations acting as provider sponsored health plans assuming full-risk contracts, similar to Geisinger Health System, Intermountain Healthcare, or Northshore Long Island Jewish Health System. Another strategic option is to offer insurance products directly to the market, either alone or in partnership with a payer. Direct employer contracting allows the CIN to “commoditize” its services, potentially increasing revenue 10 to 15 percent over traditional contracts. In order for this to be achieved, provider-sponsored health plans would need to be in place accompanied by a large provider network and organized systems of care. If “payer dependencies” are removed or limited, the healthcare spend decrease translates into revenue opportunities for the CIN.

Target Financial Opportunities to Mitigate Risk

One key to reducing the risk of value-based care is to take full advantage of its unique financial opportunities. Pay attention to four categories:

  • Infrastructure cost savings. Creating a strong shared administrative and care management infrastructure can allow a CIN to reduce per-member per-month (“PMPM”) costs 20 to 30 percent within 5 to 10 years.
  • Increased volume. Entering into narrow-network contracts with payers and employers can drive strong membership growth and patient volumes.
  • Increased domestic utilization. Minimizing patient leakage allows the CIN to maximize influence over care transitions and quality, a key to controlling costs.
  • Advanced care programs. Hospitals have the opportunity to develop advanced clinical programs and centers of excellence. Offering these programs to other network providers will increase revenue while further leveraging network effects.

The Starting Point

As you plan and launch a CIN, keep in mind one absolute necessity. Your organization must offer a strong value proposition to participating providers, payers, and patients.

For physicians, participation in your network must be an opportunity to improve patient care through access to care management, as well as clinical program and technology resources. Your CIN should also provide a management infrastructure that eases the challenges of practicing medicine today. It must facilitate care redesign to enhance care efficiency and patient focus, and optimize clinical resources.

For payers, your network must provide higher quality care, better patient outcomes, and better patient access, all while reducing the cost of care.

For patients, your network must provide access, affordability, and tools to facilitate care coordination and engagement.

A strong value proposition is key to finding the right “change momentum” for your organization. Focusing on providing value helps make sure you do not embrace change too quickly for your market. It also ensures your organization can maintain a steady forward pace by balancing appropriate risk with solid potential for clinical and financial gains.

Daniel J. Marino, The Camden GroupMr. Marino is a senior vice president with The Camden Group with more than 25 years of experience in the healthcare field. Mr. Marino specializes in shaping strategic initiatives for healthcare organizations and senior healthcare leaders in key areas such as population health management, clinical integration, physician alignment, and health information technology. He may be reached at dmarino@thecamdengroup.com or 312-775-1701.
 
Clinically Integrated Networks, CIN, Clinical Integration, The Camden Group

Topics: Clinical Integration, CIN, Clinically Integrated Networks, Daniel J. Marino, The Camden Group

Quick Survey: Participation in a Clinically Integrated Network

Posted by Matthew Smith on Sep 17, 2014 3:42:00 PM

Survey, online surveyAs healthcare costs continue to rise, payers are putting pressure on all providers to deliver more coordinated care. Hospitals and physicians are now expected to collaborate to improve outcomes, reduce utilization and control costs.

What does this mean for medical practices? Physicians have only a few options.

One alternative is to seek employment by a hospital or health system. The benefit of employment is a certain level of income security for physicians. The downside, of course, is loss of autonomy.

The second alternative is to remain independent. While this option preserves physician control, it exposes doctors to new risks. In the coming years, payers will continue to put pressure on physicians to accept lower reimbursement. Physicians’ negotiating leverage will continue to decline.

Fortunately, a third alternative is now emerging—clinical integration between physicians and hospitals. A clinically integrated network allows physicians to work collaboratively with a hospital, other physicians and post-acute providers. Under the right legal structure, clinical integration allows physicians to maintain independence while benefiting from joint contracting based on quality outcomes and cost management.

Please answer this quick survey regarding your organization's participation in a clinically integrated network. Your responses are anonymous. Questions 1 & 2 pertain to hospital personnel. Questions 3 & 4 pertain to medical practice personnel.
 
Results will be shared in a HD Insights Blog post next week. Thank you for your participation. (Please note scroll bar within survery.)

 

Topics: Clinical Integration, CIN, Clinically Integrated Networks, Survey, Medical Practice, Employed Medical Practice

The Next Wave of CI: Regional Clinically Integrated Networks

Posted by Matthew Smith on Sep 15, 2014 11:13:00 AM

Clinically Integrated Networks, Clinical IntegrationHospitals across the country are partnering with local physicians to form clinically integrated networks. The goal is to coordinate care around quality outcomes and cost management.

But the drive to manage outcomes and costs is leading many local networks into the business of population health. That, in turn, is putting pressure on the boundaries that separate one clinically integrated network from another. There is a growing awareness of the need to coordinate care at a regional level.

Now, provider organizations in many areas are responding to this need by developing “Regional Clinically Integrated Networks (CINs).” This is good news:

  • Regional CINs hold the promise of delivering truly effective population health management.
  • The Regional CIN model can accommodate the many hospitals and physician groups that want to take part in a coordinated care strategy, but continue to have a strong preference for remaining independent.

Defining “Regional” Clinical Integration

Clinically Integrated Networks, CIN, Clinical IntegrationA Regional CIN is collaboration between multiple hospitals within a wide geographic area. The hospitals remain independent while pooling clinical, technological and strategic resources. This includes employed physicians as well as strategically important community physicians within their local networks.

Expanding the organized system of care allows participants to better influence quality outcomes, reduce costs and pursue value-based contracting. Factors driving the Regional CIN trend include:

  • Significant interest from independent physicians in partnering with hospitals in response to healthcare reform.
  • The desire of many independent hospitals to develop a population health management strategy without participating in a merger.
  • The need of large regional health plans to secure provider partners in developing population health insurance products.

The Regional CIN Planning Process

An effective regional network strategy will focus on four key goals:

Create a Vision and a Business Strategy

Begin by defining the population health goals of the Regional CIN. Identify the resources needed to achieve these goals, develop financial models and forecasts, and craft a comprehensive budget. Take care to develop an appropriate legal structure for the network.

Define a Payer Strategy

Start by identifying potential managed care partners. Some Regional CINs are focusing first on their own employees. Member organizations are pooling their self-insured beneficiaries and enrolling them in the Regional CIN. This allows participants to reduce their direct healthcare costs. More important, it enables the network to create a “proof of concept” that can later be promoted to payers.

Develop a Shared Infrastructure

Focus on building the key competencies of population health management:

  • Coordinated medical management around clinical protocols
  • Leveraging of information systems to optimize patient care
  • Clinical, financial and operational analytics/reporting
  • Provider enrollment and integration
  • Alignment of financial incentives with network goals
  • Risk-based contract negotiations

Build a Shared Culture

Organizational culture drives the effectiveness of any provider network. While pushing to grow the Regional CIN, leaders should also carefully consider provider eligibility and selection criteria.

Three questions that drive regional strategy

As a first step to developing a Regional CIN, healthcare leaders should ask:

1. Is There an Opportunity?

What is the state of care coordination in your region? Is there an opening for a true population health approach? What community health needs represent your most promising starting point?

2. How Will Participants Benefit?

How would a Regional CIN create value for each member hospital? What’s in it for physicians?

3. What Resources Can We Leverage?

What services can be pooled and leveraged for greatest impact? Do potential partners have enough self-insured employees to launch a “beta version” of the population health concept?

The most important question for many organizations will be, “How soon can we begin?” Providers across the country are actively developing the Regional CIN model as a “platform for change” that will help them thrive in the emerging healthcare environment.

Apps Pdf icon For a PDF version of this article, please click here.


Daniel J. Marino, Clinical Integration, CINAs President/CEO of Health Directions, Daniel J. Marino shapes strategic initiatives for healthcare organizations and senior health care leaders in key areas such as population health management, clinical integration, physician alignment, and Health IT. With a broad background in all aspects of practice management and hospital/physician alignment, Dan is nationally recognized as a strategic leader in Accountable Care Organizations and clinical integration development. He frequently speaks at national conferences and regularly authors articles for the nation’s top healthcare industry publications related to current transformations in healthcare delivery. Dan may be reached via email at dmarino@healthdirections.com or by phone at 312-396-5400.

Clinical Integration, Health Directions, Clinically Integrated Network

Topics: Population Health, CIN, Clinically Integrated Networks, Regional Clinical Integration Networks

Infographic: The Transformation of Healthcare IT

Posted by Matthew Smith on Sep 9, 2014 11:13:00 AM

Health IT, HIT, Data AnalyticsIt could be said that data is the fuel and HIT systems are the pipeline for managing Population Health. Building the data infrastructure for a population health program is a complex undertaking with considerable upfront investment. Provider organizations must build a strategy, manage their cost structures, and understand the accountable care functions and IT systems that are necessary to make ACOs, CINs, and other population health initiatives function properly.

This infographic by Logicalis examines the rapid change affecting the healthcare IT field--and provides some valuable statistics regarding:

  • Mobile Communications
  • Use of Analytics for Care Improvement
  • Patient Access & Engagement

To view a full-size version of this infographic, please click here.

Health IT, HIT, Healthcare IT,

 

Data Analytics, ACO, Healthcare Data

Topics: ACO, Clinical Integration, Population Health, HIT, Health IT, Infographic, CIN, Healthcare Analytics, Clinically Integrated Networks

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