LEE PHYSICIAN HOSPITAL ORGANIZATION DEVELOPMENT OF CLINICALLY-INTEGRATED NETWORK CLINICAL INTEGRATION FREQUENTLY ASKED QUESTIONS

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1 LEE PHYSICIAN HOSPITAL ORGANIZATION DEVELOPMENT OF CLINICALLY-INTEGRATED NETWORK CLINICAL INTEGRATION FREQUENTLY ASKED QUESTIONS 1. What is clinical integration (CI)? Clinical integration is an effort among physicians, often in collaboration with a hospital or health system, to develop active and ongoing clinical initiatives that are designed to control costs and improve the quality of health care services within the community. Participation in an effective and appropriately structured CI program will provide independent physicians the ability to contract collectively with insurers and employers without violating antitrust laws. 2. Why are physicians across the country engaging in CI? Physicians have numerous and overlapping motivations for joining together in clinicallyintegrated networks, including: (1) to enhance the quality of care provided to patients, (2) to legitimately negotiate with payors as a network, (3) to gain access to technological and quality improvement infrastructure that will be essential for success in an increasingly valuebased payment environment, and (4) to allow networks of physicians and hospitals to market themselves on the basis of quality and cost. 3. In real life, what does a CI program look like? In many instances, clinical integration has involved physicians (both independent and employed) on the medical staff of the same hospital or hospital system who join together in an organizational structure that allows them to: (1) identify and adopt clinical protocols for the treatment of particular disease states, (2) develop systems to monitor compliance with adopted protocols on both an inpatient and outpatient basis, and (3) enter into contractual arrangements with fee-for-service health plans in a way that financially recognizes the physicians efforts to improve health care quality and efficiency. In addition, long-standing, mature CI programs often exhibit several common characteristics, including: A well-defined organizational structure that is capable of promoting strategic goals while protecting individual interests. A physician-led governing body that is supported by professional management resources. A robust IT platform that enables the exchange of clinical information across care settings, supports clinical decision making at the point of care, and permits the generation of reports that reflect performance related to high-priority clinical areas. A network of highly-engaged physicians that are committed to adhering to evidencebased medicine guidelines and clinical protocols related to specific disease states/clinical conditions. 2039\01\221568(docx) 1

2 Clearly defined contracting strategy and related payment methodologies that incentivize care coordination and quality improvement across participating physicians. The ultimate goal of such a program should be to foster interdependence among physicians and enable them to achieve higher quality and greater cost-effectiveness than they likely could achieve on their own. 4. What effort has been made to develop a CI program in our market? In March 2013, the Lee Physician Hospital Organization (Lee PHO) engaged a national healthcare consulting firm to conduct an assessment of its capabilities to establish and support a CI program under risk-based contracts. The assessment found that the Lee PHO is well positioned and has a unique opportunity to support the physicians transition to valuebased care and to be viewed as a national model for collaboration. Based on these findings, the Lee PHO Operating Committee, a physician-led governing body responsible for setting the strategic direction of the PHO, elected to move forward in the development of a CI program to be operational by early How will physicians be involved in the leadership of this endeavor? The development of the CI program is being led by the Lee PHO Operating Committee, which is a 15-member governing body that is comprised of a minimum of 12 physicians (at least 9 of whom are independent physicians). Additionally, the Operating Committee is supported by a series of subcommittees, each responsible for a specific area of focus as it relates to the implementation and ongoing operation the CI program. Each of the subcommittees, which are listed below, is led by a team of independent and employed physicians that have been actively engaged in the process of developing the CI program. Clinical Management Subcommittee. Contracting Subcommittee. Credentialing Subcommittee. Data and IT Subcommittee. 6. Once operational, which patient populations will be targeted as part of the CI program? It is important to note that clinical integration is a journey rather than a destination. As a result, the scope of the CI program, both in terms of patient populations and clinical focus areas, will likely evolve over time as the Lee PHO and participating physicians develop the capabilities (e.g., infrastructure) and expertise in population health management. Initially, the CI program will focus on improving the quality of care and reducing costs related to members covered under the LMHS self-funded employee health plan. The employee population is an ideal starting point because LMHS already assumes financial risk for members of the plan and has access to detailed claims data, which reflects the total cost of care across all health care settings. Over time, however, it is likely that Lee PHO will expand the CI pro- 2039\01\221568(docx) 2

3 gram to other patient populations, including commercially-insured patients, Medicare advantage beneficiaries, and employees of self-insured employers. 7. What will physicians need to do in order to participate in the CI program? While the physician leadership has not yet finalized the elements of the CI Program, it is likely that physicians will be asked to do the following: First, because participation in the CI program will be completely voluntary, physicians will need to choose whether they will participate and are able to meet the requirements of the CI program. The Operating Committee recently approved certain minimum criteria for physicians/groups that will participate in the CI program, including: Participate in the development and utilization of evidence-based clinical care guidelines, as approved by the Operating Committee, and other CI initiatives intended to improve the quality of care and reduce costs. Meet or exceed clinical performance standards established by the Operating Committee related to CI initiatives. Make available the information necessary to implement/operate the CI program, including patient clinical data, medical records, and billing/claims data. Invest in and utilize applicable IT capabilities deemed necessary for the CI program, including high-speed Internet access, communication, and certain IT systems/solutions required to effectively coordinate care. Participate in CI program orientation, as well as ongoing training initiatives (e.g., IT, clinical care guidelines) as necessary. As requested by the Operating Committee, participate in the various committees charged with overseeing and operating the CI program. Second, physicians will be required to collaborate with their physician colleagues in the evaluation and implementation of care protocols for specific clinical conditions that will enhance the quality, service, and cost-effectiveness of patient care. Third, physicians will need to hold themselves and each other accountable for compliance with the care protocols associated with the CI program, including its performance improvement/outreach and disciplinary efforts should physicians not meet the benchmarks set by the CI program. 8. Isn t this CI program just an effort by LMHS to take over my practice? Absolutely not. The CI program is a physician-led initiative. Physicians in private practice who choose to participate will maintain their existing practice status. It is important to note that more than half of the physicians on the Lee PHO s governing committees, which are responsible for implementing and operating the CI program, are independent. 2039\01\221568(docx) 3

4 9. What role will physicians employed by LMHS/Lee Physician Group (LPG) plan in the CI program? The physicians employed by LMHS/LPG are expected to participate in the CI program and become early adopters of the collaborative behaviors needed to drive quality and cost improvements. However, the Lee PHO requires that the governing committees maintain balanced participation between employed and independent physicians and between primary care and specialist physicians. 10. What clinical initiatives will the CI program include? Although the CI program is still in the process of development, similar programs have included efforts designed to facilitate and improve: Chronic disease management. Community case management. Improved use of generic drugs. Adoption and utilization of key IT resources. Communication and sharing of information among primary care physicians and specialists. Others areas of focus. In general, the goal of these clinical initiatives is to enhance the value of services provided to patients and payor communities, and measure performance with the initiatives using data from various sources including: claims processing and adjudication systems, practice management and scheduling systems, disease registries, pharmacy benefit systems, and hospital and ambulatory EHR systems. 11. Will participation in the CI program require physicians to change the way they practice medicine? Yes. Participation in the quality and care management initiatives of the CI program will require significant time and attention from physicians and their office staff. These initiatives will be developed by the Clinical Management Subcommittee and will focus on reducing costs and improving patient care across multiple clinical conditions. 12. How will I be paid for achievement of quality and other performance-related measures? As it relates to LMHS s employee health plan, participating physicians will continue to be paid under their existing fee-for-service arrangements. Additionally, physicians will likely be eligible to share in any savings that is generated as a result of improved quality and efficiency through the CI program based on their individual performance across applicable performance measures. However, the actual funds flow model that will be used to distribute these savings to individual medical groups and/or participating physicians has not yet been finalized and is currently being developed by the Contracting Subcommittee. 2039\01\221568(docx) 4

5 13. Will I be required to purchase/utilize a specific EHR? An ambulatory EHR is not a prerequisite for the development of clinical integration. While a common EHR across all participating physician practices can certainly accelerate and strengthen a CI program, most (if not all) successful models of clinical integration nationwide do not depend on an ambulatory EHR for data on physician performance. Ultimately, a network of independent physicians may wish to implement an EHR that is designed in a manner that assists in the capture and extraction of the data necessary to continue to operate their CI program; however, the CI program will likely begin its efforts to measure, analyze, and evaluate physician performance through claims data, existing hospital data, disease registries and chart audits. 14. How can I receive more information regarding the details of the CI program? Please direct any questions you may have to the Lee PHO office at or via e- mail at anne.rose@leememorial.org. Moreover, additional information related to both the PHO, including the organization s bylaws, as well as updates related to the efforts to implement the CI program, will be made available via the Lee PHO s Web site at \01\221568(docx) 5