GE Healthcare Camden Group Insights Blog

What Can Clinically Integrated Networks Offer Physicians?

Posted by Matthew Smith on Apr 13, 2017 9:00:00 AM

By Mark Krivopal, MD, MBA, Vice President, GE Healthcare Camden Group

Much has been written about clinical, post-acute care facilities and physicians, has led health system executives to invest substantial financial and human capital to set up infrastructure and operating processes that improve value in health care.

These organizations intend to be prepared for current and future challenges such as increased regional competition, government regulations and payment reform. If the value proposition of these organizations is articulated and delivered in a genuine patient and physician-centric way, significant rewards can be gained not only by the health system itself but also by its individual physicians.

To continue reading this article and the 10 considerations for physicians when deciding whether to join a CIN, please click the button below.

NOTE: This article is password protected on the American Association for Physician Leadership website, but may be accessed by logging in with the following credentials:

Login: gehccamden@ge.com
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Clinical Integration, Clinically Integrated Networks

krivopal_M.jpgDr. Krivopal is a vice president with GEHC Camden Group and an accomplished senior physician-executive with 19 years of healthcare experience across the continuum of care. Dr. Krivopal is responsible for developing and leading innovative, value-based programs addressing client needs in healthcare organizations, hospitals, and physician practices focusing on transformational system integration strategies, service line optimization, throughput and clinical leadership development. His experience spans not-for-profit and privately held organizations of various sizes as well as start-up environment in the healthcare information technology space. He may be reached at mark.krivopal@ge.com

 

 

Topics: Clinical Integration, Clinically Integrated Networks, Physician Leaders, Mark Krivopal

What Clinically Integrated Networks Offer Physicians

Posted by Matthew Smith on Apr 12, 2017 3:05:58 PM

By Mark Krivopal, MD, MBA, Vice President, GE Healthcare Camden Group

Much has been written about clinical, post-acute care facilities and physicians, has led health system executives to invest substantial financial and human capital to set up infrastructure and operating processes that improve value in health care.

These organizations intend to be prepared for current and future challenges such as increased regional competition, government regulations and payment reform. If the value proposition of these organizations is articulated and delivered in a genuine patient and physician-centric way, significant rewards can be gained not only by the health system itself but also by its individual physicians.

To continue reading this article and the 10 considerations for physicians when deciding whether to join a CIN, please click the button below.

NOTE: This article is password protected on the American Association for Physician Leadership website, but may be accessed by logging in with the following credentials:

Login: gehccamden@ge.com
Password: gehccamden
 
Clinical Integration, Clinically Integrated Networks

krivopal_M.jpgDr. Krivopal is a vice president with GEHC Camden Group and an accomplished senior physician-executive with 19 years of healthcare experience across the continuum of care. Dr. Krivopal is responsible for developing and leading innovative, value-based programs addressing client needs in healthcare organizations, hospitals, and physician practices focusing on transformational system integration strategies, service line optimization, throughput and clinical leadership development. His experience spans not-for-profit and privately held organizations of various sizes as well as start-up environment in the healthcare information technology space. He may be reached at mark.krivopal@ge.com

 

 

Topics: Clinical Integration, Clinically Integrated Networks, Physician Leaders, Mark Krivopal

Super Clinically Integrated Networks: 8 Components to Consider

Posted by Matthew Smith on May 4, 2016 11:31:47 AM

By Susan Corneliuson, MHS, FACHE, GE Healthcare Camden Group 

Clinically Integrated Networks ("CINs") are evolving quickly across the country in response to changing reimbursement trends and the move to value-based payments. Estimates indicate more than 500 CINs are in operation in the country today.

In most markets, single healthcare systems have formed independent CINs in an effort to more formally align independent and employed physicians in the region. In certain markets, we are starting to see the development of Super CINs or Population Health Alliances. 

The formation of Super CINs and Alliances is motivated by the perceived need to reach larger populations and to form more comprehensive delivery networks, in many cases fueled by increased competition within the marketplace. The main goals of most Super CIN/Alliance structures is to expand network offerings and services through direct-to-employer products and to effectively pool resources to build robust population health infrastructures. 

Independent systems believe they can achieve greater benefits through joint collaboration than on their own and trust that they will ultimately be better positioned for value-based care. 

Alliances are formed by integrating a number of healthcare institutions under one CIN structure, in which hospitals remain independent while pooling clinical, technological, and strategic resources. This includes employed physicians and community physicians within local networks.

Super CINs are the product of multiple CINs under a single superstructure. Super CINs and alliances allow smaller systems, hospitals, and physician organizations to leverage infrastructure costs, management and governance oversight, care management protocols, population health management capabilities, as well as population financial risk while still retaining their independence.

Structuring and effectively managing Super CINs formed between competing healthcare entities is a complex undertaking that should not be pursued without clear and deliberate discussion among the respective parties. There are a number of strategic, operational, and tactical components that need to be evaluated to determine how systems can work together and what challenges may be encountered.

Eight components to evaluate before forming a CIN

1. Leadership and governance. Do the management and physician leaders of each organization understand and embrace the principles and cultural change requirements of forming a Super CIN/Alliance? Have goals and objectives been clearly identified and articulated? Can necessary cultural transformation be executed across the network to deliver on the value proposition? Are individual organizations willing to cede certain functions and/or decisions to the Super CIN?

2. Strategy, sustainability, and transformation. What strategies need to be developed to create a sustainable model? Is there market demand for the product offerings and will it disrupt existing relationships? What activities and services will be provided by the network, and what services will be retained by each individual entity? How can knowledge and expertise be harnessed across the network?

3. Network composition and access. How comprehensive and accessible is the acute, post-acute, allied provider, and facility network in meeting patient care needs? How accessible are these segments today, and what would change under the new superstructure?

4. Population health management capability. What services are required to support the network? What are the population health management and analytic capabilities of each organization? Does one entity have a greater depth of experience, knowledge, and infrastructure? How will the alliance support the integration and launch of value-based products, including network development and management, care management, claims adjudication, risk management and compliance?

5. Clinical care models and coordination. What clinical care models are in place to manage high cost, chronic disease patient groups? What are the gaps and optimal approaches to integrate care to gain efficiencies across the network? Can existing programs be leveraged and re-tooled to support a larger population base?

6. Quality, value and transparency. What quality metrics are being measured and tracked at each organization? How are outcomes reported to providers to promote cost effective and high quality care? What reporting capabilities need to be developed? What will it take to aggregate meaningful data among these groups?

7. Financial management and reimbursement. What are the current financial incentives within the respective CINs? How will funds flow models be integrated across the network to incent and reward providers for improved health outcomes?  How will risk be shared across the network versus borne by individual organizations?

8. Patient experience and activation. What communications, educational, and community support programs are needed to engage patients and improve compliance?  How will these be shared across the network?

Other challenges to consider

The assessment of these critical components is essential and requires leadership to work collaboratively with institutions that are typically considered competitors under traditional reimbursement models.

Cultural differences between Super CIN/Alliance partners can also create governance challenges particularly as infrastructure expenses and shared savings distribution discussions and modeling are initiated.

It is a time of significant transition as providers and payers begin to work under the new healthcare paradigm and a lot remains unknown. In some markets, there is still significant resistance and uncertainty about value-based payment models and overall reform.

Regardless of the skepticism, the formation of Super CINs is gaining momentum across the country. Ascension Health and CHE Trinity Health announced the launch of their alliance in spring of 2014, creating one of the largest clinically integrated networks in the country uniting 27 hospitals, 12 physician organizations, and 5,000 physicians within Michigan.

Other examples of systems that have formed super CINs  include: The Population Health Alliance of Oregon, a collaboration of seven health systems in Oregon and a major medical insurer; Greenville Health System; and Integrated Health Network, a seven health system collaboration including Froedtert Health, the Medical College of Wisconsin, Wheaton Franciscan Healthcare, Columbia St. Mary's, Ministry Health Care, and Agnesian HealthCare. 

The impact on payer contracting and a shift to value-based payment models is among the greatest challenges for both the provider and insurance sectors. As healthcare providers begin to assume more risks for their populations, the roles and financial relationships become more interdependent and blurred. In markets where Super CINs are being formed, managed care contracting has become consolidated as plans begin to work with several institutions that were previously independent.

Timing the activities around care model and financial integration is pertinent to the design of Super CINs. Legal and regulatory issues around antitrust require that the organizations be clinically or financially integrated in order to jointly contract with payers.

Fully developing the payer strategy along with the timing and phases of integration of the Super CIN will support success. However, Super CINs that do not successfully integrate and remain unable to enter into joint agreements may be left with limited functionality.

Thoughtful planning and a well-constructed and executed vision will serve all entities well as they pursue further alignment in the ever changing healthcare landscape.

This article was originally published by Managed Healthcare Executive


Susan_Corneliuson.png

Ms. Corneliuson is a senior manager with GE Healthcare Camden Group and has over 15 years of healthcare management experience. She specializes in physician integration strategies, practice assessments, operational improvement, care and workflow redesign, and compensation arrangements. She is the co-author of The Governance Institute’s signature publication for 2012, Payment Reform, Care Redesign, and the New Healthcare Delivery Organization. She has a strong background in physician practice management with experience in medical foundations, provider-based clinics, and specialty hospital settings. She may be reached at susan.corneliuson@ge.com.


 

 

Topics: Clinical Integration, Clinically Integrated Networks, Susan Corneliuson, Super CIN, Super Clinically Integrated Networks

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

Clinical Integration: There Will Be Winners and Losers

Posted by Matthew Smith on Feb 8, 2016 1:13:28 PM

Due to increasing deductibles and our improving ability to care for conditions in outpatient settings, hospital admissions have declined consistently over the past few years, and industry experts do not expect this trend to reverse. In response, healthcare systems are investing millions of dollars in acquiring physician practices and affiliating with independent physicians through clinically integrated networks in an attempt to enlarge their patient base.

Though clinically integrated networks do enlarge the patient base, one of their aims is also to reduce the percentage of admissions from that base.

There is hardly a healthcare system in a competitive market in the U.S. that is not pursuing some form of clinical integration strategy, and competition is being felt in more and more communities. Healthcare leaders know our society is headed towards payment-for-value and away from fee-for-service payment, and they do not want to be found without a competitive value-oriented structure.

Leaders should not assume, however, that just because they invest in clinical integration that their patient bases will be adequately enlarged to keep their hospitals filled. Their competitors are also spending millions on clinical integration strategies in hopes of enlarging their bases! The base does not automatically enlarge because an investment is made. Ultimately, there will be winners and losers.

More Than a Marketing Strategy

Winners will tend to get their fully functional clinically integrated network to market quicker than their competitors and ultimately, winners must create networks that perform better than those of competitors. Specifically, they will do a better job than competitors at controlling the cost of care and demonstrating higher quality and service. The creation of a clinically integrated network must not be just a marketing or physician alignment strategy – it must truly enable effective population health management.

As quality, cost and service information on healthcare providers becomes more readily available, individual consumers and employers will choose networks that provide greater value. Competition will put pressure on under-performers. Some systems that have invested in clinical integration will go out of business or be acquired by more successful systems, which in turn will downsize or divest those facilities.

Physician Competition Heats Up

Likewise, competition among physicians will heat up as consumers have more data upon which to make educated choices. Again, there will be winners and losers. Physicians who chose to not join narrow networks will lose access to patients. If there is an over supply of certain specialists in a certain geography, those who have poorer access, service or quality outcomes will get fewer referrals than others.

We like to think that no healthcare facility or provider should be forced to change or go out of business. We like to think that all of us can grow our patient bases to sustain our hospitals. We often act as if just the right number of facilities was built in a geographic area and that just the right number of physicians decided to go into each specialty. But we know at the macroeconomic level that none of this is true. Informed consumers will give us incentive to change, and some will win through effectively managing change, and some will lose by ignoring reality.

Topics: Clinical Integration, William K. Faber MD, Clinically Integrated Networks

Clinical Integration Via Strategic Physician Engagement: 7 Approaches

Posted by Matthew Smith on Jan 26, 2016 3:19:40 PM

New payment models make it more important than ever for hospitals to collaborate with physicians. From readmission penalties to bundled payments to Accountable Care Organizations ("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 approaches 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.

Topics: Clinical Integration, Clinically Integrated Networks, Physician Engagement

Content Download: The New Paradigm of Patient Access

Posted by Matthew Smith on Dec 15, 2015 1:23:09 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—sometimes 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 popular 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

Please click the button below to access the download page:

Patient Access, The Camden Group, Clinical Integration

 

Topics: Clinically Integrated Networks, Patient Access, Download, CINs

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

Patient Access Innovations: Integrating Patients Within the System of Care

Posted by Matthew Smith on Dec 1, 2015 3:21:44 PM

Provider coordination is of paramount importance for healthcare organizations preparing for the industry’s shift in focus from volume to value. The most ambitious coordination model that has been developed to date is the clinically integrated network ("CIN")—a contractual collaboration among hospitals, physicians, and other providers to manage patients across the entire continuum of care. A CIN uses population health management tools, including care management techniques, to build value through improving patient outcomes and controlling costs. This innovative model offers providers access to value-based payment contracts and an opportunity to improve quality and reduce costs.

Despite the compelling benefits of clinical integration, this approach also poses risks. Value-based payment contracts hold CIN participants accountable for both clinical and financial outcomes, although the ability to influence these outcomes depends largely on patient choice and patient compliance. Whenever a patient leaves the CIN, even if the patient returns to the network for certain services, network providers lose the opportunity to fully manage the patient’s care and utilization, ultimately undercutting their ability to coordinate the patient’s care and accrue the benefits of improved clinical outcomes and reduced costs.

This risk makes it critically important for CINs to keep patients within their organized systems of care. CINs need to make sure patients can access the network easily and are motivated to stay connected, requiring a strategic focus on patient access and engagement.

Based on the experiences of leading CINs, strategies aimed at improving patient access tend to be most effective when they are focused on three primary objectives: expanding entry points to the network, making access more convenient and inexpensive, and keeping patients engaged in the care they receive from network providers. The following five strategies, in particular, have been proven effective for ensuring in-network access and strengthening patient engagement.

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 Patient Access, Clinically Integrated Networks

Topics: Clinical Integration, Clinically Integrated Networks, Patient Access, Patient Engagement, Daniel J. Marino, Value-Based Payments

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

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