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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 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 does not require physicians to participate in each clinically integrated payer contract negotiated by the network. Participation in the 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. CVQCN is not an HMO or an IPA. However, providers in CVQCN 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 other health plans independently or through another independent practice association (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. CVQCN 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.

What role do Dignity Health and the hospitals have in making decisions for the network?

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

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. CVQCN has formed an ACO and is participating in the Medicare Shared Savings Program (MSSP). Participation in CVQCN’s ACO is separate from participation in the CI network and requires a separate addendum to the Participation Agreement.

What benefit will Mercy Medical Center Merced 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 at Mercy Medical Center Merced, the hospital is 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
Why are physicians across the country engaging in clinical integration?

Physicians have several motivations for participating in clinically integrated networks, including:

  • Enhancing the quality of the care provided to patients
  • Legitimately negotiating with payers as a network
  • Developing their own alternatives to health plan “report cards” and other initiatives that may not accurately assess physicians
  • Providing access to technological and quality improvement infrastructure
  • Allowing networks of physicians and hospitals to market themselves based on quality
Why do so many physicians view clinical integration as a good business and healthcare strategy?

Doctors and hospitals nationwide are implementing clinical integration programs because they believe in its value proposition:

1. Clinical integration allows physicians to:

  • Demonstrate their quality to current and future patients
  • Choose the clinical measures against which they will be evaluated
  • Share in appropriate care management, care coordination and technology tools that allow the physicians to participate in the health system in a more integrated way

2. Clinical integration gives hospitals the ability to:

  • Develop a better, more collaborative relationship with their medical staff
  • Demonstrate their quality to current and future patients
  • Enlist physician support for hospital initiatives, including compliance with “core measures,” clinical pathways, standardized order sets and supply chain management initiatives

3. Clinical integration provides patients with

  • Greater stability in their relationships with their doctors and hospitals and less likelihood that they will need to choose new healthcare providers every year
  • A better value for their healthcare dollar
  • More effective care management and outreach from a trusted source—their physician
  • More reliable information to support their choice of health plans, physicians and hospitals
  • More accurate and meaningful provider ratings

4. Clinical integration gives employers:

  • Allows employers to provide a more integrated model of care for their employees that focuses on quality outcomes and efficiency in healthcare
  • Increased employee productivity and reduced absenteeism through better management of chronic disease
  • The ability to more effectively manage the healthcare costs of employees and their dependents through the purchase of better, more efficient healthcare
  • Lower healthcare costs over the long term through the reduction of variation in physician practice patterns
  • More reliable information to support conversion to consumer-driven health insurance products