What is a clinically integrated network?
Clinical integration is collaborative, coordinated care among health care providers. The focus is on improved quality, increased efficiency, improved patient and family care experience and reduced costs. A clinically integrated network may include physicians, acute care hospitals and health systems, post-acute facilities, and other types of healthcare providers, such as pharmacies. Clinically integrated networks develop clinical protocols, measure performance against the protocols, build care management systems to engage patients, implement technology to support these initiatives, and reward providers for high quality care. As a result, communities should become healthier, patients should be more engaged, and health care should be better coordinated.
What is the purpose of the clinically integrated network?
As health insurance costs continue to rise, health plans are reducing payments for volume and are instead rewarding value and outcomes based performance. Payment models are moving from fee-for-service payments to value based contracts that provide incentives for quality and efficiency. Clinically integrated networks provide the infrastructure for value based contracting through technology and systems designed to prevent illness, manage chronic disease and coordinate care across the continuum. A newly formed primary and specialty care network entity known as Women & Children’s Health Alliance expects to receive incentive payments earned through value based contracts with hospital networks, payors and purchasers. After covering certain expenses designed to support participating physicians in delivering clinically integrated care Women & Children’s Health Alliance plans to distribute incentive payments to physicians and other participating providers based on quality and efficiency.
What are the benefits to participating?
Among other benefits, participating physicians will have access to: Clinical protocols that are developed by their local colleagues; Care management resources that engage high risk patients with chronic illnesses; New payment models with financial incentives for quality outcomes; Participation in a preferred network; Opportunities for reduced billing expense; Reduced malpractice premiums; Reduced health benefits for providers and employees; Reduced payroll processing expense; Improved HR management; and Opportunities to enroll in a vaccine consignment program to reduce vaccine expense.
What are the requirements to participate?
Among other requirements, participating physicians will: Participate in quality and cost improvement programs that include sharing clinical and cost data with Women & Children’s Health Alliance; Comply with certain eligibility criteria; Support care management programs developed by Women & Children’s Health Alliance; Abide by policies, procedures, and performance standards adopted by, Women & Children’s Health Alliance; Obtain and maintain participating provider status with contracted purchasers; Pay an initial participation fee and annual dues; Appoint Women & Children’s Health Alliance as its agent to negotiate certain contracts; and As requested, actively participate in Women & Children’s Health Alliance committees. A goal of the Women & Children’s Health Alliance program of clinical integration is to ensure that patients of participating providers have the benefit of the program’s quality initiatives through their continuum of care. Accordingly, for members of plans (or beneficiaries of governmental programs) contracted with Women & Children’s Health Alliance, participating providers shall endeavor to utilize the resources of, and refer patients being treated pursuant to and within the scope of such contracts, to other Women & Children’s Health Alliance participating providers, in accordance with Women & Children’s Health Alliance policies.
Who owns Women & Children’s Health Alliance? How is it governed? Will I have input?
Participating practices have invested funds in the infrastructure and operation of Women & Children’s Health Alliance, and all participating practices are members of Women & Children’s Health Alliance. Physicians who participate in Women & Children’s Health Alliance through participation agreements will have the opportunity to be members of the Board and committees, as well as serve other roles in the organization. In addition, all participating physicians and their practice staff will have the opportunity to attend town hall style “learning sessions” to share best practices across the network. We are committed to a truly physician led governance and management structure which maximizes and values physician input. Participating physicians are expected to serve on committees to develop and implement clinical protocols, determine outcome metrics, and monitor performance.
How does this impact my participation in other Clinically Integrated Networks or Shared Savings arrangements?
Participating providers will not be permitted to participate in other clinically integrated networks or shared savings arrangements that involve the same covered lives as Women & Children’s Health Alliance shared savings arrangements. However, participating providers may enter into any contract with a payor covering any product or plan that a Women & Children’s Health Alliance payor contract does not cover. In addition, the Women & Children’s Health Alliance Board of Managers may make limited exceptions to these requirements based on Women & Children’s Health Alliance network needs, such as geography or access issues.
Will Women & Children’s Health Alliance contracts displace my current payor contracts?
All of your current fee-for service based payor contracts will remain as is and will continue for a period of time, since the initial focus of the Women & Children’s Health Alliance will be to contract on behalf its participating providers only for so-called “value based contracts”, such as governmental and commercial pay for performance, shared savings or bundled payment contracts. Upon meeting certain clinical integration requirements established by federal antirust regulatory agencies your current may be replaced by Women & Children’s Health Alliance payor contracts upon renewal.
Will Women & Children’s Health Alliance negotiate contracts beyond shared savings models?
Yes, Women & Children’s Health Alliance may negotiate contracts for the upside or shared savings component only, or Women & Children’s Health Alliance may negotiate for the base fee component of services.
Does the Women & Children’s Health Alliance have any contracts? Will the CIN negotiate payor contracts?
Not at the current time. Upon development of certain clinical integration infrastructure components and securing participation agreements from a sufficient number and mix of specialty and primary care physicians, Women & Children’s Health Alliance will commence detailed discussions with payors and or other clinical integration partners, such as children’s hospitals and health systems. As stated previously, Women & Children’s Health Alliance will not negotiate third-party rate based payor contracts on behalf of its network of participating providers until it has determined that those negotiations are pursuant to a program of clinical integration or substantial financial risk sharing.
Will participation require physicians to change the way they practice medicine?
Participation requires physicians to support Women & Children’s Health Alliance quality goals, utilize clinical protocols, and meet standards of performance that are developed by Women & Children’s Health Alliance clinical committees.
What role does the EHR have? How will I submit data?
An EHR that interfaces with a health information exchange or other population health management technology solution of the network will provide the best means for collaborative care among Women & Children’s Health Alliance providers. However, in the absence of an EHR that interfaces with such technology solutions, data can also be submitted to a secure web site. Shared claims and data will support care coordination across the continuum and provide the method to assess outcomes.
Are there limitations on my ability to refer patients to providers outside of Women & Children’s Health Alliance?
In-network referrals assure that patients receive the consistent care that is included in physician developed clinical protocols. Also, in-network referrals support sharing of patient data, leading to more coordinated and efficient care. In addition, existence of in-network referrals represents a key requirement established by antitrust regulators for designations as a clinically integrated network.
What type of data will be monitored?
Required data will include the clinical indicators related to the value based contract outcomes. See CMS examples.
Can an individual physician participate or is participation limited to a practice?
Physicians can participate as individuals or as a practice, although participation of all physicians in a specialty or primary care practice, following the network’s program of clinical integration present the greatest opportunity for superior clinical and financial performance.
Who will see my data and outcomes?
Aggregate data will be used by the Women & Children’s Health Alliance leadership and clinical committees to measure the success of the clinical programs and to identify opportunities to improve care. Individual physician results will be reviewed if there is an opportunity to improve the overall performance of Women & Children’s Health Alliance. At least quarterly, participating physicians will receive individual or practice outcome reports.
Do I have to join now?
Certain physicians are being invited to participate. Physicians who join now may be considered “in-network” for initial discussions with payors and will be eligible for incentives if/when they exist. Physicians who do not join now will be evaluated for participation annually or as network needs are identified.
If I join as a participating physician, am I or my practice being acquired, employed or otherwise financially controlled?
No. Your decision to join Women & Children’s Health Alliance does not change the current legal or financial status of your practice. You maintain control of your day-to day operational and staffing decisions as well as practice financial matters such as compensation, benefits, finances and banking relationships. You are only being asked to “re-think” the way you deliver care in order to respond to changing payment and delivery systems emerging in our market.