Q: What is “clinical integration”?
A: Clinical integration is an effort among physicians, often in collaboration with a hospital or health system, to develop active and ongoing clinical initiatives that control costs and improve the quality of healthcare services through care coordination. A properly developed and implemented clinical integration program usually involves independent and employed physicians working with a hospital or health system, as well as other healthcare providers, to improve quality and care delivery.
Q: What are the characteristics of effective clinical integration programs?
A: An effective clinical integration program contains initiatives that: (1) provide measurable results, which (2) evaluate physician performance, and (3) result in concrete improvement of that performance. Clinical integration fosters interdependence and care coordination among providers and enables them to achieve higher quality and greater cost-effectiveness than they likely could accomplish on their own.
Q: In “real life,” what does a clinically integrated network (“CIN”) look like?
A: In most instances, a CIN involves a network of physicians and affiliated hospital(s) who create a legal and governance structure, management, and operational capabilities to: (1) identify and adopt clinical protocols for the treatment of a wide range of disease states, (2) implement technology and human resources to facilitate care coordination and care models that improve patient health, (3) develop systems to monitor compliance with the adopted protocols on both an inpatient and outpatient basis, and (4) establish contractual arrangements with payers who are willing to financially recognize the network’s efforts to improve healthcare quality and efficiency.
Q: Why would physicians want to participate in a CIN?
A: Physicians have several motivations for participating in CINs. Typical reasons include: (1) enhancing the quality and efficiency of the care provided to patients, (2) availing themselves of tools that will help them and their office staff manage complex patients (care coordinators, information technology), (3) enabling the sharing of clinical information with peers and colleagues and to better access information that can be used to care for patients, (4) creating an organized structure that gives physicians a greater “voice” in designing clinical improvement programs, (5) providing a vehicle to participate in new payment models that pay physicians incentives for cost and quality improvements.
Q: Will physicians be involved in the development of the CIN that Memorial Health Care System is facilitating?
A: Yes. A new clinical integration entity, Mission Health Care Network, has been created for the explicit purpose of developing and implementing a clinical integration program. The majority of board members are physicians, and physicians lead and participate on committees that develop and maintain all components of the clinical integration program.
Q: What benefit is there in partnering with Memorial Health Care System in the development of a CIN?
A: Memorial is committed to collaborating with physicians on the development of the CIN. It views this initiative as critical to the ability of the physicians and hospital to successfully respond to expectations of employers and payers to improve the health status of our community, while also controlling the costs of high quality healthcare. It is committing resources to provide legal, business, and technical advice to assure that the CIN can be established and operational quickly, and will be successful in working with a variety of payers. Through its relationship with Catholic Health Initiatives, the CIN will have access to national contracts/pricing with advanced information technology and data exchange companies and tools to facilitate care coordination.
Q: How is it lawful for clinically integrated networks to jointly negotiate with health plans?
A: Federal antitrust enforcement authorities, including the Federal Trade Commission (FTC), view robust clinically integrated physician networks as potentially creating efficiencies and improved quality of care, which can provide greater value to patients and employers (who pay for health insurance). The clinically integrated networks that have been formally approved by The Centers for Medicare and Medicaid Services (CMS) as accountable care organizations (“ACOs”) are also recognized as meeting the standards of being clinically integrated. However, the FTC will continue to prosecute those networks that fail to implement true clinical integration, or seek to use the approach as a way of simply obtaining greater reimbursement without added value.
Q: Will Mission Health Care Network (the CIN) negotiate payer contracts for physician services?
A: The CIN will not negotiate fee for service contracts unless and until the CIN and its participants are financially or clinically integrated as required by law. The initial focus will be on shared savings opportunities through which CIN participants will be able to earn compensation in addition to their regular fees by providing high quality care and reducing the total cost of health care services incurred for a population of patients.
Q: Why should we pursue clinical integration now, in Chattanooga?
A: Employers in our community are concerned about the rising cost of healthcare. They are pushing health insurance companies to reduce premiums, which in turn means that health plans are less willing to give physicians and hospitals rate increases. As the physician-led network matures and develops operating experience, its board will be able to consider other payer contracting strategies and arrangements. CMS is implementing ways to change the traditional fee-for-service payment system for Medicare patients. All in all, there will likely be less money paid on a traditional fee-for-service basis to physicians and hospitals, and future payment opportunities will be based on demonstrating an ability to improve patients’ health and to control the overall cost of healthcare for a population of patients. We need better tools to do that, and it is far more cost effective to implement the information technology, care coordination resources, and data analytics together than it would be as individual physician practices or a hospital alone. We can lead the redesign of our healthcare delivery system by facilitating physician-physician dialogue, developing better tools to improve patient engagement in their care, and assuring that transitions of patient care are seamless.
For more information, email us at missionhealth@memorial.org.