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What are the characteristics of an effective clinically integrated program?

Clinical integration fosters interdependence among providers who, by working together on the quality initiatives they select for the program, are able to achieve higher quality and greater cost-effectiveness than they likely could accomplish on their own.

What does a clinically integrated network of independent physicians look like?

In most instances, clinical integration involves a hospital and physicians on its medical staff who create committees and management capabilities to:

  • Identify and adopt clinical protocols for the treatment of particular disease states
  • Develop systems to monitor compliance with the adopted protocols on both an inpatient and outpatient basis
  • Contract with fee-for-service health plans and local employer self-insured plans in a way that financially recognizes the physicians’ efforts to improve healthcare quality and efficiency
Does clinical integration require me to place my fees at risk in a “withhold” or capitation model?

While clinical integration uses many of the same quality improvement and medical management techniques that would allow for effective management of capitation, it currently does not require the use of withholds or capitation. As healthcare reimbursement models change in the future, members of the network may opt to participate in contracts that have downside risks.

Will I be able to negotiate with other doctors in the program for better fee-for-service rates from the health plans?

In successful clinical integration programs, value-based contracts with fee-for-service health plans can include incentives that recognize the value of the higher quality and greater efficiency furnished through the clinical integration program.

Can we participate in just the contracts that we choose?

The clinical integration program agreement requires physicians to participate in each clinically integrated payer contract negotiated by the network. Participation in the Bundled Payment for Care Improvement (BPCI) or Medicare Shared Savings Program (MSSP) is voluntary.

Do all members of the group have to participate if we sign up under a group agreement?

The participation agreement stipulates that all members in a group must participate.

Will this affect my referral patterns?

Participation in a clinically integrated network does not mandate any change in referral patterns. The network is not an HMO or an IPA. However, providers are held to certain performance standards and we believe this translates to a higher quality of care.

Does participating affect my other payer contracts?

Membership is non-exclusive and does not limit a physician’s ability to contract with (IPA), physician organization (PO) or physician hospital organization (PHO).

My staff cannot take on more work. How will this affect my practice?

Joining a CI network will provide additional resources including assistance in navigating the Merit-based Incentive Payment System (MIPS). The goal is to not add more work to physicians’ staffs. The network provides educational opportunities for your staff through ongoing staff Lunch & Learns to keep your staff current and up-to-date on healthcare news that may impact your practice.

Why can’t care coordination support all of my patients?

The care coordination team currently supports patients who are part of the CI network’s contracts and can assist with providing information on community resources for other patients.

Do the CI network’s quality metrics replace measures in other CMS quality programs?

Federal Trade Commission (FTC) regulations require a CI program to measure and report on the quality of the care provided within the network. These measures have been designed to overlap other CMS quality programs; however, they are not a replacement.

Is a CI network an ACO? Is it an IPA?

A CI network is neither an ACO nor an IPA. A CI program can involve independent and employed physicians working with a hospital or health system who contract collectively with fee-for-service health plans without violating anti-trust laws. Participation in an ACO is separate from participation in a CI network and requires a separate addendum to the Participation Agreement.

What benefit will hospital partners provide in developing a clinical integration program?

Partnering with a hospital or health system can provide distinct advantages to a network of independent physicians in the development of clinical integration. In instances where the hospital shares the same quality vision as the physicians, as is the case here, the hospitals are a powerful ally in program development by:

  • Collaborating with the physicians in developing clinical integration initiatives based on existing inpatient quality measures
  • Lending financial assistance and personnel in implementing inpatient and outpatient initiatives that provide true community benefit and are not tied to the referral volume or value
What role do Dignity Health and the hospitals have in making decisions for the network?

The network is physician-led. Its board of managers is composed entirely of physicians with one hospital representative.