Health systems with clinically integrated networks are seeing financial benefits — a trend which is expected to continue alongside the shift away from fee-for-service payment models.
In a presentation at Becker's Hospital Review 5th Annual CEO + CFO Roundtable, Nishant Anand, MD, and Douglas Monroe, MD, spoke on how hospitals can develop this type of strong clinical integration.
Here's what they had to share:
1. Use policy to your advantage. The Medicare Access and CHIP Reauthorization Act, which is led by CMS, provides incentives to practices that have joined Alternative Payment Models — including a selection of coordinated-care networks, called ACOs.
"It affords you a lot of waivers, a lot of benefits, a lot of opportunities to collaborate," said Dr. Anand, the senior vice president and physician-in-chief at Memorial Hermann Physician Network and chief medical officer at Memorial Hermann ACO in Houston. "It's going to be key to make sure we leverage MACRA and make sure that's something we can align our physicians with."
MACRA, which impacts how physicians are reimbursed when caring for Medicare beneficiaries, is a value-based care program. Its ultimate goal is to reward hospitals based on clinical and quality performance, rather than volume.
"You have to mitigate clinical risk in this new era, in order to mitigate financial risk," said Dr. Monroe, a physician at Chicago-based Prism Healthcare Partners. "They are now inextricably tied."
2. Establish a tiered system of partners. "Should you get a highly-efficient, small network, or should you make it large to make sure you have enough physicians to refer into your network? I think you actually have to do both," said Dr. Anand.
Dr. Anand suggested the use of a three-tiered concentric ring model, with "advanced practices" in the central ring, followed by a "clinically integrated accountable care network" and, finally, a "messenger model" in the outer ring.
The messenger model encompasses participating providers who are loosely affiliated with the organization; these partners may refer patients to the network's hospitals, for example. The central advanced practices segment — "where we really formed our top-notch network," according to Dr. Anand — encompasses primary care physicians and specialists.
Today, Memorial Hermann has about 57 clinical performance committees comprising roughly 500 physicians. "The heart of any clinically integrated network is going to be sharing best practices," Dr. Anand said.
3. Engage in plans for strategic growth. Dr. Anand spoke about three methods for strategic growth: network delivery, covered lives and service line products.
Network delivery strategies encourage organizations to develop partnerships with a range of services, including acute care, home care, ancillary, post-acute and retail care services. Covered lives strategies encourage organizations to consider the plans that they cover — including Medicare at risk plans, Medicaid at risk plans, commercial at risk plans, health exchanges and self-funded plans.
Premiums, in particular, require a comprehensive strategy, from benefit design and health plan-network contract to pharmacy. "When I first started, everyone was focused on 'decrease your costs, decrease your utilization,' but with a fully-integrated clinical network, you have to look at the pharmacy costs, you have to look at your network contracts, you have to look at your health clinic and you have to partner with your payers in the market," Dr. Anand said.
Service lines focus on a few key areas, including patient satisfaction, supply savings, observation hours, quality and length of stay.
4. Utilize consistent performance evaluation. Dr. Monroe suggests routine assessment of five critical success factors to encourage clinical improvement: leadership/culture, management structures/reporting systems, data availability/analysis, performance improvement methodology and physician/clinician engagement.
"You need to have common understanding and robust reporting — and transparent reporting — processes, and you have to have the discipline to do that every month to two months," Dr. Monroe said.
To develop clinical improvement capabilities, he suggested first reviewing foundational elements and clinical support structures before designing and implementing a clinical enterprise support structure. His final step focuses on designing and implementing integrative clinical infrastructure, including the implementation of a specialty-focused committee structure and the initiation of education- and evidence-based improvement cycles.
Establishing performance improvement processes is the key to becoming a hospital with benchmark performance, according to Dr. Monroe. "It's not that they've mastered surgical site infection, or patient safety metrics, or other discrete metrics," he said, in reference to these successful organizations. "What they have mastered is a central and standardized approach to evidence-based performance improvement."