GE Healthcare Camden Group Insights Blog

Asked and Answered: Frequently Asked Questions by Physicians About Clinically Integrated Networks

Posted by Matthew Smith on Sep 21, 2015 3:35:11 PM

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

While clinical integration development continues to build momentum, many questions still remain. The following questions and answers will help communicate the value of clinical integration and clinically integrated networks ("CINs") to your physicians. If you're a physician, these questions and answers should help you with some recurring and nagging issues.

What is clinical integration?

Clinical integration is an effort among physicians, often in collaboration with a hospital or health system, to develop active and ongoing clinical initiatives focused on delivering quality, performance, efficiency and value to the patient.

What’s driving the movement toward clinical integration?

In the years ahead, physicians and hospitals must partner more closely than ever before to ensure that the community receives the highest quality and value. As we move from today’s fee-for-service reimbursement models to new performance- and value-based pay models, CINs enable healthcare providers to join together to enhance the health of a community. These networks bring value to patients, payers, and physicians by improving transitions of care, coordinating chronic disease management, and managing the health of a population.

What does a CIN do?

A CIN helps physicians align with the hospital to coordinate care across caregivers, focus on quality and performance, and prepare for new, incentive-based compensation programs in addition to the base compensation they already receive. The network will develop new payment systems and methods that focus on achieving quality, efficiency, cost-management measures, and enhancing value.

What is the purpose of the CIN?

The principal purpose is to enhance the quality and efficiency of patient care services provided by the participating providers to the community. A CIN with participating providers works together to develop clinical performance standards and protocols for the network. These will form the basis for the network to negotiate contracts with payers for performance incentive programs.

How is it structured?

The CIN is a wholly owned subsidiary of the health system managed by its own Board of Directors, with community physicians and hospital members. Physicians willing to participate in a meaningful way have the opportunity to be involved in the organizational committees that drive the network.

What are the benefits of joining?

For physicians, the network offers the opportunity to:

  • Become available as a preferred network provider to members
  • Use care management resources provided by the CIN
  • Identify and measure best practices
  • Improve outcomes for patients
  • Receive financial rewards for value-based outcomes and achievements

The goal of the CIN is to provide an exemplary patient experience and improve the health of individuals in our community in a continuum of care that is focused on quality, performance, efficiency, and value. This serves as the platform that will determine financial incentives for physicians.

Who can join?

To ensure the best value for patients and payers, the CIN welcomes physicians who want to be accountable and raise the quality of care. These physicians can be:

  • Independent community physicians who seek clinical and quality alignment
  • Physicians employed by a health system
  • Physicians who contract with the hospital to provide services in specialties such as emergency medicine, anesthesiology, and pathology

Do physicians join as individuals, or do all the physicians in a practice need to join?

For independent physicians, a delegated representative from a group practice may sign the participation agreement and code of conduct on behalf of the practice to enroll all providers. However, in most instances, each individual physician in the group will need to complete a short application packet. Physicians employed by the health system will be enrolled with other members of their practice groups.

Will members be required to refer enrolled patients to other network members?

In-network referrals allow for the efficient accumulation and reporting of data, promote coordination and continuity of care and ensure adherence to evidence-based medicine.

What type of data is monitored?

Network leaders and physician advisory committees will determine details on clinical initiatives and data to be monitored and reported. Collected data likely will be similar to that being measured for Medicare programs, such as the Physician Quality Reporting System.

How will clinicians submit data to the network?

Providers will submit clinical and claims data on a timely basis to a secure, web-based platform that is HIPAA compliant and password protected. The web-based platform enables physicians to conveniently and easily submit data from any device with internet access.

What is the difference between a CIN and an Accountable Care Organization ("ACO")?

According to the Centers for Medicare and Medicaid Services, an ACO is accountable specifically for Medicare beneficiaries. It is an organization of healthcare providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries enrolled in the traditional fee-for-service program who are assigned to the ACO. Similarly, a CIN is an alignment model, coordinating care across affiliated caregivers and developing contracts with payers to improve quality while controlling growth in total cost of care, including value-based contracting initiatives with commercial payers and Medicare.

Clinical Integration Networks, CIN, Daniel J. Marino


Daniel J. Marino, The Camden Group, Clinically Integrated NetworksMr. Marino is an executive vice president with 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 dmarino@thecamdengroup.com

 

 

Topics: Population Health, Clinically Integrated Care, Clinically Integrated Networks, Clinically Integrated Network, Daniel J. Marino

 3 Important Considerations for Funding Your Clinical Integration Project

Posted by Matthew Smith on Sep 15, 2015 1:58:54 PM

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

Healthcare leaders are asking some serious questions about clinical integration. How much will it cost to develop a clinically integrated network ("CIN")? How and when will the CIN begin paying for itself?

Here are answers to three important questions about the economics of clinical integration.

Q. What Initial Investment Will Clinical Integration Require?

The upfront investment depends on the resources each participant can contribute to the network. The initial primary cost drivers of a CIN are information technology, professional and legal support, and staffing. The good news is that all three cost components can usually be managed within the available resources of the hospital partner.

Based on the work The Camden Group is doing with clients, new CINs typically require $500,000 to $3 million in investment capital. This money funds the network build and launch over a two- to three-year period.

Q. What is the Net Impact of Clinical Integration?

Leading organizations are developing CINs with the idea that they will not achieve true return on investment until two or three years down the road. The sooner a CIN can manage population health and build an organized system of care, the sooner it will realize a net positive return. Two areas are key:

Network Impact

The CIN as a whole should focus on securing incentive payments. These include incentives tied to reducing the cost of care and meeting/exceeding quality thresholds under value-based and risk-based contracts. Networks can also pursue employer contracts that provide care management fees and revenue from employee health outreach, wellness, and prevention services.

Participant Impact

Hospitals and physicians that participate in a CIN can expect a positive impact within their separate operations.

  • As network-driven care matures, patient outmigration (commonly referred to as patient leakage) outside the CIN should decrease by 10 percent to 15 percent. Hospitals will see their utilization increase, even though typical indicators such as length-of-stay and readmissions will decrease.
  • Many CINs begin by enrolling the hospital’s self-insured employed population. These hospitals will see a decrease in their variable employee costs and a decline in overall spending per employee per year.
  • Integration will also complement a hospital’s internal quality improvement initiatives. Hospitals that participate in a CIN will have a greater ability to bend the cost curve, achieve quality targets, and improve patient access.
  • Physicians have the opportunity to receive performance incentives in the form of shared savings distributions. Medical providers should also see a stabilization and eventual increase in their practice population, resulting in stronger practice revenue.
Q. What is the Financial Value of Clinical Integration?

Ultimately, CINs need to look beyond short-term incentives and start developing the ability to assume financial risk for groups of beneficiaries.

Payers are beginning to offer complementary insurance products that leverage population health management. These payers need high-performing CINs that:

  • Deliver a strong network of providers focused around organized care principles
  • Demonstrate the ability to drive down costs for high-risk population cohorts
  • Incorporate care coordination functions that result in high-quality care outcomes

CINs that can deliver on these points will build undisputed financial value, giving them a commanding position within emerging provider/payer partnerships.

Start with a Financial Model

Will your CIN be economically viable? The answer depends on many variables, including market forces and assumptions inherent in population health management.

The first step for any new CIN is careful financial modeling. Successful CINs get a fast start by building sophisticated financial models that take into account changing conditions and sensitivity analyses. These models help CINs build strong provider networks, align participants with a population health vision, maximize their net economic impact, and create true financial value. 

Clinical Integration Networks, CIN, Daniel J. Marino


Mr. Marino is an executive vice president with GE HealthcareCamden 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: Clinically Integrated Care, Funding Clinical Integration, Clinically Integrated Network, Daniel J. Marino, Funding CINs

Population Health Alliances: Rethinking the Business Model

Posted by Matthew Smith on Mar 26, 2015 12:01:00 PM

By Tara Tesch, MHSA, Senior Manager, GE Healthcare Camden Group

Healthcare systems are increasingly choosing to partner with other provider organizations to pursue population health initiatives on a more regional and sometimes state-wide basis. These “alliances” are often viewed as alternatives to more traditional mergers and acquisitions, and are created through the collaboration of more than one health system, hospital, or physician group. This emerging collaboration model provides opportunities to share common infrastructure, expand geographic reach, and increase access to additional clinical and support resources. These alliances also face additional challenges associated with sponsorship by multiple organizations that in some cases have historically been competitors.

The Next Generation of Physician Engagement Strategies

The healthcare environment is changing at a rapid pace and the path toward population health requires committed physicians, administrators, and clinicians at all levels and across the continuum of care. These leaders must commit to taking accountability for clearly communicating the transformational vision, goals, and objectives of the population health alliance to unite its members around this effort. Success in engaging the providers will be around demonstrating a true desire and understanding of the critical importance of integrating physician and clinicians into all levels of the alliance’s governance and operations.

Key to meeting this strategic imperative is to engage dynamic, knowledgeable physician leaders with creditability among the broader physician network to proactively meet with the front-line physicians and build support and engagement. Do not assume that established structures (e.g., medical staff meetings, etc.) will always be an effective means to distribute information and build engagement.

Additional strategies that have proven successful for alliances include:

  • Ongoing education for community-based providers in clinical integration, innovative care models, and tracking of clinical quality and outcomes aimed at increasing their understanding of the value of participation in the alliance network. Education requirements should be included in all physician agreements, and dedicated staff and resources assigned to support these efforts.
  • Leadership training and support to empower the next generation of physician leaders to jointly problem-solve and collaborate in achieving the tenets of population health. Set the tone that this is a transformational journey that will have successes and mistakes; jointly learning from them will offer new insights and promote future efficiencies in ongoing value-based care delivery planning and implementation.
  • Transparency in communication and evolving metrics are necessary to keep providers informed and engaged, and to elicit critical behavioral change. Adjustments in reimbursement, care models, coding requirements, IT systems and capabilities, and alliance-wide goals should be distributed regularly followed by timely educational sessions. Physicians can no longer focus only on their individual performance; rather, focus must shift to the care of their patients across the network continuum, and feedback on how appropriate interventions and utilization of care can improve the health of the populations served.

Adding Value to Physicians

Another critical concept in understanding best practices in physician engagement and network development is the realization by alliance and member system leadership that physicians only practice one model of care; they do not change that approach based on what payer or “bucket” the patient may be attributed. Where alliances can add true value to physicians and actively engage providers is in support services such as care management and IT platform/analytics – areas to support efficiency and provide actionable information in real time.

  • Create a centralized care management institute at the network level that includes performance improvement and care management resource support that can be accessed by other organizations if they do not have their own resources for local work efforts.
  • Establish an ongoing monitoring process, overseen by the alliance clinical committee to measure and track improvement in a clinical indicators over time. This active monitoring and validation helps to test whether or not the data is accurate, the metric(s) is (are) appropriate, and if the process in place actually impacts performance/outcomes.

A consistent challenge remains around providing meaningful data at the point-of-care to educate and engage providers around their performance on clinical quality and financial outcomes. As value-based care delivery relies on care model transformation, physicians rely more and more on receiving actionable information around their clinical outcomes, adherence to evidence-based guidelines and protocols, and value-based metric performance to impact behavior change and operational tools to support practices in care redesign.

The new care models and payment methodologies associated with population health management will require more tightly aligned financial and clinical incentives between hospitals and physicians. Initiatives in these areas must be physician-led to achieve sustained success clinically and financially.

One final consideration: employment does not guarantee physician alignment or integration. The same principles of engagement hold true whether employed or independent, and incentives that align with targeted behavioral change become increasingly important for longer-term success and transformation. Design incentive plans that not only encourage productivity, but reward physician efforts to achieve shared goals in care, quality, and cost control.

Parts two and three in this series will focus on Care Redesign and Data Governance, respectively.


tara

Ms. Tesch is a senior manager with more than 18 years of experience as a healthcare leader and strategist. Ms. Tesch specializes in value-based care delivery strategic planning, CIN development and implementation for commercial, Medicare, and Medicaid populations, health information technology data governance and analytics strategy, as well as care management strategy, design, and implementation. She has worked with a variety of healthcare providers, including integrated delivery networks, academic health centers, regional referral centers, rural community providers, and national non-profit and faith-based health systems. She may be reached at tara.tesch@ge.com

 

Topics: Clinical Integration, Population Health, Clinically Integrated Care, Physician Engagement, Population Health Alliance, Tara Tesch

New Download: Population Health Management--What Does It Mean To Your Practice?

Posted by Matthew Smith on Sep 8, 2014 11:00:00 AM

Clinical Integration, Clinically Integrated Care, Population Health

The time has come for primary care physicians to reboot their practice operations and begin the process of managing population health. Many physicians are delaying the planning and implementation process that will prepare them for a transformation of how they are paid from fee-for-service to reimbursement-for-results. 

This new PDF presentation from Health Directions examines current trends in Population Health Management as they pertain to physician practices and addresses such topics as:

  • Population Health Defined
  • The Building Blocks of Clinical Integration
  • ACO/Clinically Integrated Network Components
  • Case Study: Forming an ACO
  • Key Implementation Steps
  • Implications for Physicians and Office Managers
  • Participation Considerations

To access this presentation, please click the button below:

Population Health, Practice Management, Clinical Integration

Topics: Clinical Integration, Population Health, Clinically Integrated Care, Physician Practice, Clinically Integrated Network, Download

HD Download: Top Questions From Physicians About Clinical Integration

Posted by Matthew Smith on Aug 21, 2014 4:14:00 PM

FAQ, Clinical IntegrationClinical Integration programs unite physicians for the purpose of delivering higher quality health outcomes. Payers in certain markets reward systems with Clinical Integration programs due to the savings created by better population health management. Physicians are sometimes reluctant to join Clinical Integration programs and appropriately ask “What’s in it for me?” 

While our previous article, titled "5 Incentives for Enlisting Physicians in a Clinical Integration Program" examined the "What's in it for me" question, we received some great feedback asked for more answers to commonly received questions. This FAQ will help you communicate the value and details of clinical integration and a clinically integrated network to your physicians. If you're a physician, these questions and answers should help you with some recurring and nagging questions.

Top Questions Include:

  • What’s driving the movement toward clinical integration?
  • What is the purpose of the clinically integrated network?
  • What are the benefits of joining?
  • Who can join?
  • Do physicians join as individuals, or do all the physicians in a practice need to join?
  • What type of data is monitored?
  • How will clinicians submit data to the network?
  • What is the difference between a Clinically Integrated Network and an Accountable Care Organization (ACO)?
  • and more.

Do you have a question that is not included in the FAQ? Feel free to share your question in the comments section and we will address these in a follow-up document.

To download the FAQ, simply click on the button, below:

FAQ_Button_Orange.png

Topics: ACO, Clinical Integration, Hospitals, Clinically Integrated Care, FAQ, Physicians

Clinical Integration: A "3rd Way" for Hospital-Physician Collaboration

Posted by Matthew Smith on Aug 4, 2014 8:15:00 AM
By Daniel J. Marino
President/CEO
Health Directions

Clinical Integration, CI, Clinically Integrated NetworkAs 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.

The Benefits of Clinical Integration

Independent physicians can benefit from a clinically integrated network in four ways:

Autonomy Within Collaboration

Clinical integration allows physicians to maintain their independence while coordinating patient services across the entire continuum of care. A clinically integrated networkenables autonomous medical practices to participate in collaborative care teams and measure comprehensive quality outcomes.

Negotiation Leverage

Clinically integrated networks create value with payers by coordinating quality tracking, performance outcome measurement and cost management for network providers. As an approved legal structure for provider collaboration, a clinically integrated network can contract for enhanced reimbursement through shared savings and/or performance incentives.

Population Health Support

In the near future, population health management will become a key tool for improving patient outcomes and controlling costs. But independent physicians cannot afford to build a population management infrastructure. A clinically integrated network can provide the technology to track quality outcomes, the organizational structure to integrate patient management with other providers, and the tools to identify and influence the cost of care.

Protection Against Payment Risk

Payment models will continue to evolve rapidly in the years ahead. Physicians who align themselves with a clinically integrated network will stay on the forefront of opportunities to benefit from new contracting approaches, new reimbursement structures and new ways to maintain accountability for contract performance.

3 Questions to Ask

Independent physicians who are considering joining a clinically integrated network should ask three questions:

Are Physicians Leading the Network?

Successful clinically integrated networks are governed and led by physicians. Hospital leaders should participate in setting strategic direction, but physicians must have a leading role in developing clinical programs, designing financial incentives and building the provider network.

Are You Willing to Adopt New Care Models?

Innovative care models are key to achieving the goals of clinical integration. Independent physicians must be willing to incorporate new models into their clinical workflow. This could include enhanced use of EMR, participating in care teams and incorporating certain patient care services that may not currently be reimbursed.

Are You Willing to Make a Long-Term Investment?

The financial benefits of a clinically integrated network might not be realized for 12, 18 or 24 months. Participating physicians must be willing to invest their time in building an innovative delivery network that will only pay off in the future.

While the benefits may take time to materialize, clinical integration is a promising alternative for physicians. Joining a clinically integrated network now is a sound strategy for preparing your practice for the future.


Daniel J. Marino, Clinical Integration, Health DirectionsAs 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, Physician Engagement, Health Directions

Topics: Clinical Integration, Clinically Integrated Care, Medical Practice, Clinically Integrated Network

Building the Four Pillars of Clinically Integrated Care

Posted by Matthew Smith on Jul 28, 2014 1:19:00 PM
By Daniel J. Marino,
President/CEO, Health Directions

4 Pillars of Clinical Integration

Government and private insurers are gradually moving away from encounter-based reimbursement and rapidly developing new payment models that reward coordination of care and population health management. How should healthcare leaders respond? As always, there are options.

The first option is to do nothing. Both hospitals and physicians can maintain current strategies based on fee-for-service payment, avoid the up-front costs of care coordination — and tolerate declining reimbursement. Physicians will take home less pay, and hospitals will see their margins shrink.

The next option for hospitals and physicians is to work on improving care coordination, but within their respective silos. A hospital could use quality methodologies and technological tools to improve coordination of inpatient care. A physician group could develop a medical home model to coordinate care within its practice population. "Siloed coordination" will enable each party to leverage gains in payor contracting. Hospitals will be able to point to cost reductions, and physicians will be able to tout better chronic disease outcomes. The problem is that neither the hospital nor the physicians will realize the benefits of fully coordinated patient care. Their opportunities for success under value-based contracting models will be limited.

That brings us to the last option: clinical integration between hospitals and physicians. Clinical integration offers both parties the opportunity to coordinate patient interventions, manage quality across the continuum of care, move toward population health management and pursue true value-based contracting.

Unfortunately, the path to clinical integration is far from clear. The best strategy is to build a platform for hospital-physician collaboration that is flexible enough to support a broad range of possible futures. Right now, leading healthcare organizations are creating this versatile platform by focusing on the four "pillars" of clinical integration.

Clinical Integration Collaboration1. Collaborative Leadership

The first pillar of clinical integration is a shared governance body with strong physician leadership. Getting governance right is critical for three reasons.

First, if a clinical integration initiative will include independent physicians, it needs to have a legal structure for contracting with payors and, in turn, paying physicians based on outcomes, not referrals. To be acceptable under Federal Trade Commission standards, a clinically integrated organization must be an independently governed entity with the objective of improving population health through coordinated programs and interventions.

Second, clinical integration requires collaboration on payor strategy. The scope goes beyond the typical Physician-Hospital Organization. The focus is on achieving clinical outcomes that can serve as value drivers within risk-based and pay-for-performance contracting models. Only a strong physician-led governance body will be able to create the clinical strategies required to pursue risk-based or value-based contracts with commercial payors, develop innovative care contracts with employers and take advantage of accountable care opportunities in the Medicare Shared Savings Program.

Third, clinical integration requires a strong physician-led governing structure for driving cultural change. For a clinically integrated organization to be successful, physicians must transition away from the fee-for-service mindset. This includes adopting new behaviors that align with outcomes-based reimbursement, such as collaborating across specialties, sharing information, managing utilization and providing proactive care. Educating providers on clinical integration concepts, including innovative care delivery models and tracking of clinical quality outcomes, is what allows community physician members to understand the value of participation.

2. Aligned Incentives

Hospitals and physicians share many goals, but their priorities often diverge. It is essential that clinically integrated organizations develop structures that align goals and incentives across the entire spectrum of providers.

Clearly, physician compensation is an important tool. Clinically integrated organizations must design incentive plans that not only encourage productivity, but reward physician efforts to achieve shared goals in care, quality and cost control.

But compensation design is not enough to ensure strong performance. Organizations need to create support structures to help physicians understand and work toward performance objectives:

Develop a plan for communicating strategies and decisions to the entire organization.
Assign staff and resources to physician education and office staff training.
Develop a provider scorecard that keeps physicians oriented toward improving clinical outcomes and controlling costs.

Supporting all of these efforts, leaders need to build a financial infrastructure to guide overall decision making. One key priority is to develop a risk-based cost model that links patient care costs to interventions and quality outcomes. Finance leaders will also need to begin engaging with payors to explore and negotiate risk-based contracts and develop a physician performance incentive fund.

3. Clinical Programs

The heart of clinical integration is care coordination. Greater coordination between providers will improve patient outcomes and wring costs out of the system by optimizing care transitions, reducing redundant testing and providing better management of patients with multiple complex co-morbidities and diagnoses.

To launch a care coordination strategy, begin by creating clinical programs that target major opportunities in care improvement. Initial areas of concentration may include:

High-risk patients (for example, diabetics with multiple co-morbidities such as hypertension or heart failure)
Cost-control opportunities (like generic prescribing and MRI utilization review)
Key public health initiatives (such as smoking cessation and depression screening)

The next step is to develop appropriate clinical performance measures. For example, an asthma care program could track asthma control rates, screening frequency and percentage of patients with an up-to-date asthma action plan. The program could also track cost measures such as drug expenses, physician visits and emergency room visits.

Clinical programs should also develop care plans that define care protocols for various conditions. Program leaders can use process mapping to create care pathways that encompass ambulatory, inpatient, post-acute and home health interventions. Care gaps reports can be created to identify opportunities to enhance delivery of patient care according to care protocols and measure clinical care performance by care setting.

Physicians who are used to encounter-based reimbursement need guidance on how to be successful within a clinically integrated initiative. Support should focus on helping physicians manage patients within care plans through the use of care coaches and care coordination tools. Many physicians will also need coaching on how to incorporate nurses, dietitians and other support providers into care efforts aimed at managing the patient outside the traditional office setting.

Proactive medicine is key. Traditionally, a physician knows that a patient has a problem only when the patient comes in for an appointment. The success of clinical integration will hinge on physicians' ability to anticipate and prevent patient problems. To do this, physicians will need to incorporate care gap reports into clinical care and adopt new processes — for example, assigning a nurse to call patients with high-risk diabetes to ensure hemoglobin A1C is reported according to the defined diabetic clinical treatment protocol.

4. Technology Infrastructure

New connectivity and point-of-care tools make hospital-physician collaboration more possible than ever. The risk is overspending on technology and under-delivering on functionality. The key to avoiding these problems is to create a focused IT investment strategy.

The first priority is to invest in technologies that support coordination of care. One approach is to develop a health information exchange that connects ambulatory electronic medical records (of both employed and independent physicians), the hospital EMR, pharmacy information systems, labs, etc. The goal is to create a patient longitudinal record that allows physicians, nurses and other providers across the care community to track patient care in every setting.

Next, begin investing in technologies that support population health management. A clinically integrated organization needs to be able to aggregate and analyze clinical data so it can identify performance shortfalls and strategize improvements. Stage 1 meaningful use data from the ambulatory EMR and Physician Quality Reporting System can serve as a starting point, but to achieve significant gains in quality and cost, the organization needs comprehensive clinical and claims data from disparate information systems. The solution is to create a disease registry, a database that enables an organization to capture information from various provider systems and sources. The key is to incorporate a tool that allows the clinically integrated organization to run performance analytics on clinical programs, care settings, provider performance and cost utilization.

Clinically integrated organizations should also invest in technologies for connecting patients. Patient electronic engagement — via patient portals and secure messaging — is a requirement under stage 2 meaningful use. Beyond the requirements, organizations should explore patient portal and personal health record technologies for involving patients more deeply in clinical programs.

Tying it all Together

The overall goal of the four-pillar platform is to link clinical outcomes to cost management with the aim of negotiating value-based payor contracts. In light of this goal, clinically integrated organizations need to be able to aggregate data for the entire network and compare outcomes to community performance.

For example, a clinically integrated organization might set the goal of reducing high-risk diabetic patients from 12 percent to 8 percent of its patient population, compared to a community-wide rate of 10 percent. If the organization can achieve this outcome and demonstrate it with valid data, it will be in a position to negotiate favorable risk-based or shared savings performance contracts that enhance revenue and drive patient volume.

Looking Ahead

While both hospitals and physicians have several options for taking advantage of new payment models, clinical integration represents the best opportunity for both parties. The key to success is a flexible strategy that emphasizes effective governance, aligned incentives, clinical programs and appropriate technology.

None of these pillars can be built overnight, but leading organizations are making steady headway in each area. Clinical integration is not a project with a defined endpoint, but an evolution that will require ongoing attention, quality improvement, resources and leadership.

 

Clinical Integration, Health Directions, Population Health

 

Daniel J. Marino, CIN, Clinically Integrated Networks; As 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.

Topics: Clinical Integration, Hospitals, Clinically Integrated Care, Physicians

Use a Collaborative to Build a Clinically Integrated Culture

Posted by Matthew Smith on Jul 23, 2014 1:57:00 PM

By William K. Faber, MD, MHCM
Chief Medical Officer
Health Directions

Practice Transformation Collaborative, Clinical Integration, To succeed in emerging payment models, providers must cooperate to improve patient outcomes and control costs. This requires not just new workflows, but a new provider culture. Learn how to create a Collaborative to align provider culture with the needs of a clinical integration initiative.

Traditional fee-for-service payment rewards the isolated efforts of providers. But patient outcomes are not maximized by individual effort. They are maximized by team effort. In accountable care systems, providers must coordinate their efforts to improve health outcomes and contain costs. Systems must transform both clinical operations and clinical culture to achieve success. One proven strategy for developing a new provider culture is to create a Practice Transformation Collaborative.

What is a Collaborative?

A Practice Transformation Collaborative is a longitudinal and interactive learning program that helps healthcare providers understand and use the tools of quality improvement. It brings together physicians and key clinical team members to learn practice management and quality improvement principles. It focuses them on specific quality metrics and the best evidence-based means to reach them. Participants receive practical guidance on improving office efficiency and effectiveness. They share their experiences, receive peer support and learn best practices from one another.

Used effectively, a Practice Transformation Collaborative can help providers within a CI system become adept at improving population health outcomes and simultaneously minimizing costs. Well-designed collaboratives share six key elements:

1. Clinical Leaders with Quality Improvement Experience

Effective programs are spearheaded by clinicians with experience in quality improvement. A good candidate might be a physician with an MPH or MS in Quality Improvement. Support faculty should include physicians and nurses with experience, certification or training in quality. Successful teams also benefit from instructors with expertise in lean process improvement.

2. An Operational Director

A collaborative is a large undertaking that needs a focused director. Responsibilities include developing the budget and curriculum, setting up meetings, enrolling providers, developing promotional materials, designing incentives and organizing ongoing events. This role does not need to be a full-time position. In smaller organizations, these responsibilities could be handled by a PHO director, a QI director or someone in business development.

3. A Curriculum

A strong curriculum will introduce participants to the concepts of population management, Clinical Integration, process improvement, chronic disease management and practical statistics. It is important to include a “workshop” component that gives participants an opportunity to work together, compare notes and learn from real-life projects.

4. Peer-to-Peer Interactions

The heart of a Collaborative is the peer sharing process. Instructors teach principles and give assignments, but the true learning occurs as clinicians attempt to change specific processes back in their practices and then share what they have learned with their peers. Participants can learn just as well from successes as they can from failures, and the personal sharing of successes and failures, insights, struggles and innovative ideas is both practically useful and motivational for others in the group.

5. An Ongoing Support Structure

Devise ways to support providers between sessions. One option is to require participants to turn in monthly progress reports on their projects. This could be as simple as a one-page form for reporting accomplishments and challenges. Monthly conference calls help keep participants focused on program goals. In addition, create a “tool kit” (patient education hand-outs, chronic disease management protocols, etc.) to support participants in their efforts.

6. Strong Incentives for Provider Participation

An organization could provide points towards incentive payment thresholds for collaborative participation. Other options include providing a stipend or arranging for participants to receive CME credit. It is also possible to obtain specialty board credit towards recertification for those fully participating in the collaborative.

Executive Sponsorship is Critical

As with all change initiatives, executive commitment is critical to a Practice Transformation Collaborative. Effective collaboratives are backed by a key executive leader who supports the concept, works to secure resources and provides high-level sponsorship.

About the Author

William K. Faber, MD Health DirectionsDr. William K. Faber, Chief Medical Officer for Health Directions, is a physician executive with progressive senior leadership experience. He most recently served as Senior Vice President of the Rochester General Health System in New York, where he guided the development of the system’s Clinical Integration program and assisted more than 150 providers at 44 sites through the conversion process from paper records to an Electronic Health Records system (Epic). Dr. Faber formerly participated in the governance of the Advocate Physician Partners (APP) Clinical Integration program and directed APP’s Quality Improvement Collaborative.

Topics: Clinical Integration, William K. Faber MD, Clinically Integrated Care, Collaborative, Practice Transformation Collaborative, Quality Improvement, Provider Participation

7 Steps to Achieving Clinical Integration Via Physician Engagement

Posted by Matthew Smith on Jun 2, 2014 11:18:00 AM

Clinical Integration, Physician EngagmentNew payment models are making it more important than ever for hospitals to collaborate with physicians. From readmission penalties to bundled payments to ACOs, providers have a growing economic incentive to pool resources, share information, coordinate care and services and cooperate on quality improvement. 

But while the incentives are strong, the obstacles to clinical integration are daunting. Hospital-physician collaboration is operationally complex. Although physician employment can smooth out some of the bumps, practice acquisition is expensive. While a handful of large health systems have devoted extensive resources to launching clinical integration initiatives, most smaller organizations are still sorting out their options.

How can hospitals integrate with physicians without creating political and financial problems? The solution is to focus on building mutually beneficial relationships and use existing resources wisely.

The following practical approach will help healthcare leaders achieve clinical integration by engaging physicians, strategizing collaborative programs and making targeted investments.

1. Understand Physician Motivation

Convincing physicians to collaborate more closely with a hospital can be challenging. Physicians are trained as autonomous decision makers. Perfectionism and the need for control can make it difficult to weave physicians into an integrated organization. But there is a positive side to the medical personality: No doctor wants to be an outlier.

Engage physicians by presenting data on their patient outcomes. Most physicians will discover at least a few areas in which their performance falls short of their peers.

Talk to doctors about their patients’ flu vaccination rates, medication reconciliation rates, performance on diabetes control measures, etc. This is easiest for hospitals that have access to physician claims data through a physician-hospital organization (PHO) or that offer physicians a subsidized electronic medical record (EMR) with built-in Clinical Quality Measure (CQM) templates that facilitate reporting.

Most physicians do not track and evaluate their own performance, let alone measure their performance against peers. Relevant patient statistics will earn physicians’ attention and generate interest in working more closely with hospital staff to improve outcomes.

It is also important to educate physicians on the evolving healthcare market. Explain how payers are creating incentives for clinical integration though bundled or global payments and per patient/per month care coordination fees. As physicians become more aware of these payment trends, many will embrace the opportunity to increase their salary by partnering with the hospital.

2. Create True Physician Governance

To gain the most under new payment models, physicians and hospitals have to play nice in the sandbox. The key is establishing a governance body that allows physicians to guide the development of care strategies and clinical protocols. Physician-led governance will create physician awareness and support for clinical integration initiatives and make a positive impact on the overall success of the program. Make sure the clinical integration governance committee includes physicians from solo practices and small partnerships as well as large groups. Include representatives from a range of specialties.

Most important, the governance body should include physicians who are critical or even negative about the clinical integration initiative. Often these “difficult” physicians simply want to be heard and provide their input. Making these physicians feel included will go a long way toward smoothing the transition to integration.

3. Focus on Quality, Not Finances

Physicians are concerned about productivity and payment, but concentrating exclusively on financial metrics will disenchant many providers. Focus instead on clinical quality and performance improvement. After all, this is the main reason physicians entered medicine — to provide quality care to the patients they serve.

The clinical integration committee should establish quality benchmarks and treatment protocols that define performance standards. Benchmarks can be based on evidence-based standards and care plans developed by national quality organizations and disease associations. Micromanaging clinical decisions will be unpopular, so care protocols should be broad guidelines that allow room for individual judgment.

To choose initial improvement goals, review admission and inpatient reports to identify areas of low quality and high cost. For which conditions does the hospital see the greatest number of admissions? Which conditions have the longest length of stay? Physicians using an EMR may be able to report on certain quality measures. For example, what is the percentage of hypertensive patients with adequate blood pressure control? How many heart disease patients have an up-to-date lipid profile?

Begin the clinical integration outreach with physicians in specialties linked to poorer outcomes and higher costs. Another logical starting point is primary care. Family practice physicians and internists often have the greatest impact on chronic disease management.

4. Concentrate on Care Coordination

One of the biggest opportunities in clinical integration is better coordination of care. Focus on high- and medium-risk patients who are responsible for the highest costs or who will likely increase costs in the near future. Target care transitions between the hospital and admitting specialists or primary care physicians. Involve physical therapy, home health providers and long-term care facilities in clinical coordination planning.

Physicians need to ensure that discharged patients complete follow-up visits. The hospital can assist by sponsoring a care coordination team for the entire organization to help manage follow-up appointments, referrals and home health services. To help guide care coordination, stratify hospital discharges by risk of readmission, complication or care plan non-compliance.

5. Use Technology to Get Providers Talking

Clinical integration is nearly impossible without an EMR system, but many medical practices are not far along in EMR adoption. Most practices cite expense as the main obstacle.

To overcome the cost hurdle, consider subsidizing EMR systems for practices that agree to join the integrated organization. Relaxation of the Stark laws allows hospitals to subsidize as much as 85 percent of the purchase and support costs of an EMR system. Subsidy agreements can require physicians to report quality measures and meet quality performance thresholds.

However, do not expect physicians to acquire the same EMR system as the hospital. Many small practices can do very well with free and low-cost alternative systems. The hospital should build interfaces for exchanging information with the EMR systems used by the majority of integrated physicians.

Many physicians who have implemented EMRs have participated in the Medicare and Medicaid EHR Incentive Program. As part of demonstrating Meaningful Use under the program, these physicians have already begun tracking clinical quality measures. Clinically integrated organizations should use the EMR to create aggregated quality reports and share them with physicians. Weekly or monthly reports can track disease management data such as HbA1c levels, cholesterol, blood pressure and preventive screenings. Giving physicians the chance to view quality performance metrics will engage both their competitive personalities and their collaborative spirit.

6. Build Financial Incentives

Clinical integration will require physicians to invest time and money into patient education, technology and additional staff. The problem is that methods of compensating providers for care coordination are still being developed and tested by payers. Given the costs being shouldered by physicians, financial incentives are critical.

Regardless of how incentives are distributed, hospital leaders should reward physicians either for controlling costs, achieving quality benchmarks or both. Focus on achieving care management quality metrics early on, since reduced costs tend to follow well-managed patients. Establish and re-assess these performance targets annually.

One important note: Make sure primary care physicians get a piece of the pie. Although surgical specialists might be responsible for most of the hospital’s costs and revenue, primary care doctors have the most frequent patient contact and are also responsible for most of the work of chronic disease management.

7. Invest Early for Healthy Returns

Even hospitals without the resources of a large medical system can achieve clinical integration by focusing on strategic investment and engaging community physicians through quality improvement. Hospital leaders need to allow physicians to establish the quality benchmarks and evidence-based protocols for the organization’s costliest conditions. Leaders can then concentrate on linking doctors through technology, assisting with care coordination, and negotiating with payers on bundled payments or pay-for-performance incentives.

Clinical Integration, Physician Engagement, Health Directions

Topics: EHR, EMR, Clinical Integration, Clinically Integrated Care, Physician Engagement, Coordinated Care

Who Benefits from Clinically Integrated Care?

Posted by Matthew Smith on May 28, 2014 11:11:00 AM

Clinical Integration, Clinically Integrated Care, Hospitals and physicians face mounting pressures to change their care delivery models moving from encounter-based care to population health management. This results in challenges such as:

  • Patients experiencing fragmented and uncoordinated care between the hospital, post-acute and ambulatory setting
  • Physicians unable to access the most appropriate clinical information at the point of care resulting in misdiagnosis, redundant care delivery and high costs
  • Hospital and providers struggling with managing patients with chronic diseases and complex illnesses—resulting in lower quality patient outcomes, higher readmission rates and higher costs
  • Hospitals and physicians feeling pressures from payers to accept lower reimbursement while focusing on improve patient care outcomes

A fully implemented Clinical Integration program benefits everyone in the community. Here is a look at who stands to benefit from clinically integrated care and how each group may benefit.

Patients

  • Improved safety
  • Improved quality of health care
  • Better access to the latest proven techniques and treatments
  • Streamlined interactions with health care system—less waiting and duplication
  • Fully informed physicians and medical staff

Physicians

  • Ability to spend more time with patients, less time with paperwork
  • Access to complete patient information
  • Ability to deliver higher quality care
  • Ability to monitor patient compliance
  • Ability to sell combined services of network to payors, making independent practice more viable, especially for small practices

Hospitals

  • Higher degree of effective collaboration
  • Improved clinical quality and patient safety
  • Base of independent physicians aligned with hospital
  • Ability to manage costs
  • Differentiation in the market as high quality provider

 Insurers

  • Higher subscriber satisfaction
  • Cost efficiencies and savings
  • Higher quality health care for subscribers
  • Easy access to objective utilization data

Employers

  • Containment of health care costs
  • Healthier employees

Community

  • Ability to maintain independent physician practices
  • Better health care
  • Ability to recruit medical talent to area
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Topics: Clinical Integration, Population Health, Clinically Integrated Care

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