Issue link: https://beckershealthcare.uberflip.com/i/112775
Physician-Hospital Relationships & ACO 31 of a Clinical Integration Network By Dennis Butts, MBA, Michael Strilesky, Manager, and Matthew Fadel, MBA, MSM, Senior Associate, Dixon Hughes Goodman 1. Legal options. To legally implement CI, the health system and physicians are required to organize in a structure that supports program objectives. With the exception of an employment-only model, a CI network can primarily be created within a (an): • hysician-hospital organization — A joint venture between a health P system and its medical staffs. • ndependent practice association — Owned and operated by only I physician partners. • ubsidiary of the health system — The health system is the sole corS porate member of the subsidiary entity and member physicians sign separate legal agreements to participate. Traditionally these structures have been used to negotiate and handle managed care contracts (HMO, fee-for-fervice, etc.) for a defined network of providers and they are now being utilized as the vehicle to implement CI networks by achieving the following objectives: • stablishing a network of providers that enables enhanced coordinaE tion of care. • reating a new partnership model with employed and independent C physicians that includes defined roles for physician leadership. • efining performance improvement initiatives to provide demonD strated value to the market. • roviding a platform for joint contracting to support care redesign P and performance improvement initiatives. • egotiating with potential partners for risk-based contracts. N Each legal option is capable of achieving these CI objectives and they differ in ownership structure and capitalization requirements. Some hospitals and physicians already have a PHO or IPA in place and are using those entities as the foundation for their CI programs. For example, a four-hospital system in the Midwest chose to utilize a PHO as their vehicle for CI because the business entity was already created. Although the infrastructure was not entirely created to support a fully-functioning CI network, the PHO created an opportunity for ownership, access to resources, strong public perception and the analytics staff to support quality programs. However, to limit physician costs while still allowing physicians to have a significant leadership role in the network, a four-hospital system in the southeast created a subsidiary of the health system to launch its program. 2. Physician leadership. Integration in the post-reform era requires a high degree of physician-hospital alignment that is based on trust and transparency. Health systems willing to pursue CI must empower physician leaders to have an influence on the future direction of the CI network. This will help to integrate the physician's clinical expertise into hospital operations and also increase cooperation and credibility of the CI network. Furthermore, dedicated physicians and administrative leadership will be required to successfully implement a major change project of this magnitude. A vital step to physician engagement and leadership is a robust communication strategy across the network and its partners. Clear goals and objectives by both employed and independent physicians will encourage dialogue and partnership formation as the strategy is implemented. Once the CI network is created, a governance structure should be developed. Physician leaders should participate on the CI board and provide leadership to committees formed to achieve program objectives. Other participating physicians may lead and/or participate on sub-committees supported by the CI network or health system. CI committees may merge with existing committees in place within the health system (i.e., executive committee, quality committee and contracting committee). 3. Participation criteria. Member physicians or groups in the CI network must sign a participation agreement. This agreement outlines the expectations and requirements for participation in the CI program. In the initial stages of the network, it is very critical that member physicians adhere to program guidelines to help ensure that stated objectives are met and the network's value proposition is able to be demonstrated to the market. Recognizing this, one large CI network in the Southeast included information technology adoption in the participation criteria to ensure that the network was able to demonstrate the value of enhanced coordination between providers following evidence-based guidelines. To ingrain IT utilization into the culture, not only did the CI network initially include IT adoption and utilization in the participation criteria, but the network also designated a portion of the performance incentive dollars to this area to increase compliance. As the network matures and the participation criteria is solidified into the culture, incentive payments are not typically awarded for compliance. However, to keep physicians focused on program requirements, physician eligibility in the incentive program may be tied to meeting the participation criteria. Sample participation criteria include: • aintaining the appropriate IT infrastructure. M • ogging into the CI Network website to view network and individual L performance. • ompliance with clinical protocols and care pathways developed by C the network. • articipation in all network contracts. P 4. Performance improvement. Clinical quality and operational improvement projects are necessary components of a CI program. CI provides a vehicle that engages physicians in determining how quality is defined and measured. CI also allows physicians to take an active role in care redesign and protocol development to increase quality, more effectively manage costs, reduce variation and eliminate unnecessary waste within the delivery system. The performance initiatives span across specialties and sites of care. To achieve performance improvement, the CI network works to define baseline performance and identify areas where the network can demonstrate quality and operational efficiencies to the market. It is critical that physicians play an active role in selecting metrics for the performance improvement initiatives. CI networks should select performance improvement initiatives based on the (1) feasibility of capturing sufficient data to monitor performance, (2) improvement opportunity, (3) payor, employer and/or hospital interest in the program and (4) the ability of participating physicians to impact the targeted metrics. Performance improvement initiatives can be complex and difficult to monitor effectively based on the sophistication of the network's IT system and the capacity of the network to manage multiple initiatives effectively. Recognizing this, one large multi-hospital system in the Midwest implemented their initiatives in a phased approach over time and ensured that all metrics