(PART TWO IN A THREE-PART SERIES ON CLINICAL INTEGRATION)
Clinical Integration: The Right Participants and Performance Metrics Drive Success
Clinical Integration (CI) represents a collaborative legal vehicle to allow physicians and healthcare systems to take advantage of value-based and risk arrangement-sharing payment models, while retaining the ability to continue to work in a fee-for-service (FFS) environment.1,2 The reward for establishing a CI network (CIN) is the ability to negotiate contract incentives directly with commercial payors in return for providing high-quality, cost-efficient healthcare to a specific population of patients. As an antitrust safe harbor, CI providers can jointly negotiate increased physician reimbursement rates and pay-for-performance bonuses to serve as recompense for provider costs and efforts incurred to establish a CIN. Because some payors are skeptical of CI’s financial value proposition, many CINs negotiate value-based payment models in which physicians benefit through shared savings agreements instead of higher physician base rates.2
To have the best chance of attracting value-based purchasers, CINs must build a program that can quickly address specific population needs––and because physicians are responsible for driving the clinical care of patients, the move to cost and quality accountability needs to start with them. That’s why recruiting and aligning physicians and determining the right value-based metrics and performance criteria are crucial first steps.
Secure the right mix of providers both geographically and by specialty
Many CIN’s rely on primary care physicians to be the carehub for outpatient populations. However, some networks also seek to improve inpatient performance and care handoffs, leading them to attract proceduralists and other specialists.2 Determining the appropriate physician population for a CIN means assessing the patient population characteristics and the needs of the service area, along with the competitive environment and local and national payors. That way the physician network can be appropriately sized and geographically distributed to meet market demands. If not, access limitations may lead to decreased patient satisfaction—one value-based metric of quality health care. Care coordination across a variety of ambulatory, acute and post-acute settings will be important as a CIN moves toward managing a population of patients. Organizations should focus human and financial resources on obtaining the mix of providers that will support the quality targets, service lines, geographic area cost efficiencies and other goals in their communities, aligning with local service area drivers.2
A CIN is no place for mavericks: physicians must support the quality vision
All physicians who participate in a CIN must work actively on care improvement initiatives relevant to their specialty. That’s why it’s necessary to make a selective choice of network physicians willing to adhere to standards and performance criteria, and cross-refer to participating providers. By prioritizing recruitment of physicians who are best prepared for performance improvement, or practices that expand coverage in critical market regions, CINs can avoid overtaxing their development capabilities. All members must sign a participation agreement outlining the expectations and requirements for participation. Physician participants must be comfortable with the idea of data monitoring, quality improvement and care standardization as a means to deliver more cost-effective care.
In addition, physician compensation must be tied to productivity, quality, service, cost-effectiveness, access and other strategic goals, and must provide physicians a fair and stable income. These arrangements must recognize the role the provider is playing and the differing variables that are within and beyond their control. However, finding the right balance of value-based metrics is key.3
Establish baseline clinical performance and quality guidelines to help the move toward value
Start with the basics by leveraging existing technology and data to achieve attainable, measureable performance criteria and goals. For example, the Healthcare Effectiveness Data and Information Set (HEDIS), available from the National Committee for Quality Assurance (NCQA), is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis.
Benchmark performance across care episodes to identify strengths and weaknesses
Physician “report cards” address performance strengths and weaknesses. Physician participants must agree upon value-based metrics to track things like quality, outcomes, service, patient satisfaction, overall cost of care and other operational and financial benchmarks. Indicators must be specific, measurable, attainable, relevant and time bound. They also must be reviewed on a frequent and ongoing basis. Encouraging consensus-driven care protocols and engaging physicians in best practices will help give them the grounding to thrive in a population health management environment.
The bottom line
Depending on where your organization is on the development continuum, you could be looking at a ramp-up period of 2 to 3 years to develop baseline capabilities for managing population health.3-5 And the clock is ticking. According to a recent perspective article in the New England Journal of Medicine, the US Department of Health and Human Services (HHS) has announced a goal of requiring 85% of Medicare FFS payments tied to quality or value by 2016 and 90% by 2018.6 During the same week, United Health Group also announced that they will increase value-based payments to doctors and hospitals by 20% in 2015.7 By recruiting the right providers and setting the right quality and value-based metrics, CINs can save time overall and avoid making decisions that, while appropriate for managing in a shrinking FFS environment, are less effective in a value-based setting.
To assist with your strategic planning, download Checklist #2: Does Your Organization Have the Participants and Value-Based Metrics to Lead Care Transformation?Read More