Effective clinical integration will be required of healthcare organizations as efforts to move to value-based reimbursement and population health come to fruition.
In their new book, "Developing Physician Leaders for Successful Clinical Integration," (2013, Health Administration Press), authors Carson Dye, senior partner at Witt/Kieffer, and Jacque Sokolov, MD, chairman and CEO of SSB Solutions, provide a list of 40 questions to assess any healthcare organization's clinical integration readiness.
Note: The following is reprinted with permission from Health Administration Press and appears on pages 207-209 (pdf) of "Developing Physician Leaders for Successful Clinical Integration."
Clinical integration isn’t an approach to healthcare delivery and reimbursement that you decide to pursue one day and put in place the next. Your institution needs
to be ready for it, and that readiness crosses departments, facilities, and provider organizations. To assess your readiness for clinical integration, determine where you are on this roadmap—and whether you can realistically follow it to its end.
Fast-Track Start
0-3 Months
◆ Physicians largely resistant to change
◆ Limited physician–hospital collaboration
◆ Traditional medical directorships, but no real team-based care or comanagement
of clinical services
3-6 Months
◆ Several service-line comanagement arrangements in place
◆ Physician-centric hospital-sponsored medical group structure functioning
◆ Joint physician–hospital planning committee in place
6-12 Months
◆ Additional service-line comanagement arrangements crafted
◆ Pluralistic physician–hospital governance structure in place
◆ Task force to start work on the design of the ultimate CIO
12-18 Months
◆ The CIO is fully operational, but the clinical model continues to evolve
◆ Initial VBP payer contracts are being negotiated
18 Months and Beyond
◆ Ability to deliver superior performance; quality/cost quantitative metrics in place
◆ Capable of managing full risk for a population or product
That is the overview. The specific questions you need to ask yourself to determine if you’re prepared to move to meaningful clinical integration include the following:
◆ Do you have a provider-sponsored integrated network in place?
◆ Does that network meet federal meaningful clinical integration requirements?
◆ Are you ready to plug into a variety of value-based purchasing (VBP) products with a variety of payers? That includes Medicare, Medicaid, health insurance exchanges, commercial plans, regional networks, and super CIOs.
◆ Do you have attractive geographic coverage?
◆ Are you the network of choice in your market?
◆ Here is the holy grail of clinical integration readiness on the way to VBP: Are
you an indispensable provider in your market?
◆ Are you capable of superior performance? That includes quality, patient safety,
appropriate resource utilization, and patient and provider satisfaction.
◆ Do you have a proven ability to manage risk effectively?
◆ Can your organization meet the Federal Trade Commission’s checklist for meaningful clinical integration?
– Can you show clear integration and interdependence among providers?
– Do you have in-network referrals of both primary and specialty physicians
in place?
– Do you have development, training, promotion, and tracking of clinical
standards, benchmarks, and protocols in place?
Appendix B : Clinical Integration Readiness Assessment 209
– Do you have an integrated IT platform? That means both efficient
exchange of clinical information across the care continuum and utilization
data gathered, analyzed, and shared with CIO providers.
– Do you have defined processes for tracking provider adherence to protocols?
◆ More generally, do you have a network scaled to deliver care across all settings and specialties?
◆ Do you have a legal framework and capabilities to enable joint contracting and single-signature authority?
◆ Do you have a well-defined governance and decision-making structure?
◆ Is there clear alignment of financial incentives among participants toward common objectives?
◆ Are you capable of accepting common financial risk for performance and of internally distributing revenues and expenses?
◆ Do you have sufficient numbers of patients to support comprehensive performance measurement and reporting?
◆ Are physicians engaged with you in trying to accomplish strategic goals? That includes such important areas as clinical program growth, management of cost and quality, integration and collaboration, and adoption of electronic medical records and connectivity tools.
◆ Are physicians involved in clinical program management?
◆ Are you partnering with physicians economically?
◆ Do you have an effective physician–hospital governance or management model?
◆ Are payers in your market developing VBP agreements?
◆ What is the general consensus among payers regarding contracting with provider-developed CIO or super CIO networks?
◆ Are your competitors developing CIOs or super CIOs?
◆ Are they purchasing practices and employing physicians?
◆ Are they pursuing strategies for growing market share?
◆ What are the key trends in your market?
◆ What is the existing balance of power between payers and providers?
◆ What is the potential for hospital consolidation? Who will likely be the dominant players?
Now you know where you stand. Are you ready?
To view a Q&A with author Carson Dye on clinical integration, click here.