The clinically integrated network is a key building block for the accountable care organization, an upcoming piece in the healthcare reform law that will bring together hospitals, physicians and other caregivers to deliver the full scope of care for each patient.
Advocate Physician Partners in Oak Brook, Ill., a joint venture between 13-hospital Advocate Healthcare and more than 3,400 physicians on staff, has been operating as a clinically integrated network for the past seven years. This structure allows hospitals and physicians to collaborate closely on healthcare delivery and insurance contracting without violating federal prohibitions such as antitrust and Stark requirements.
Advocate Physician Partners is now offering its clinical integration model to other hospitals through a new company called CI-Now, which is a joint venture with BDC Advisors, a nationwide healthcare consultant. Here Marty Manning, president of Advocate Physician Partners, takes a few questions on how his organization works.
Q: United HealthCare sued you, claiming you violated the Sherman antitrust law, but the suit was dismissed. Why have insurers been resisting clinically integrated networks?
Marty Manning: The clinically integrated network brings together a large group of providers contracting for care. Some insurers have called this arrangement a cartel, which would be illegal under federal antitrust laws. But the federal government has carved out an exception for groups that are clinically integrated, sharing clinical resources to improve patient care. The United HealthCare lawsuit was dismissed in arbitration in 2005 and we are in the middle of a four-year contract with United HealthCare.
Q: How does a clinically integrated network function?
MM: A central function is the patient registry. There are patient registries for a number of conditions, such as diabetes. Physicians report all their diabetics into the registry and we keep track of those patients, applying evidence-based medicine. Physicians and staff apply nine "measures of control," including process measures such as making sure they have an annual hemoglobin test. We started with 36 measures and now we have 116. Through our value reports on the Advocate website, we can show that this system reduces costs and improves quality of care.
Q: This arrangement also requires insurers to make additional payments to providers in the network. Why is that?
MM: There is no CPT code for operating a patient registry. An extra payment is needed to cover activities such as patient outreach and the IT functions, for example. This work is not recognized in a fee-for-service model, but we can demonstrate that it more than pays for itself.
Q: What role does healthcare IT play in these networks?
MM: You do need good IT, but this doesn't have to be daunting. You don’t need to start with a full-blown electronic medical record. You need to stat with a disease registry. You need the registry to tell you who are the patients with a particular condition, such as diabetics, and attribute them to a certain physician.
Q: What level of participation do you have among physicians on staff?
MM: About two-thirds of the medical staff at Advocate hospitals participate in Advocate Physician Partners, and about a quarter of those participants are our own employed physicians. Some of those who don’t participate have privileges at other hospitals and therefore cannot be fully committed. The rest are either not interested or don’t meet our requirements. We have 16 requirements, including board certification, high-speed internet access in the office and willingness to use computerized physician order entry at the hospital.
Q: What is the most challenging part of this for physicians?
MM: The challenge is adapting to the culture, which is one of cooperation and participation. This is not the old world of physicians versus the hospital. Both sides have to be partners now. They have to be really committed to the process. As you can tell by our membership numbers, most physicians want to join. That's because this organization is physician-driven. Physicians develop the guidelines. Most physicians accept evidence-based guidelines.
Learn more about Advocate Physician Partners.
Advocate Physician Partners in Oak Brook, Ill., a joint venture between 13-hospital Advocate Healthcare and more than 3,400 physicians on staff, has been operating as a clinically integrated network for the past seven years. This structure allows hospitals and physicians to collaborate closely on healthcare delivery and insurance contracting without violating federal prohibitions such as antitrust and Stark requirements.
Advocate Physician Partners is now offering its clinical integration model to other hospitals through a new company called CI-Now, which is a joint venture with BDC Advisors, a nationwide healthcare consultant. Here Marty Manning, president of Advocate Physician Partners, takes a few questions on how his organization works.
Q: United HealthCare sued you, claiming you violated the Sherman antitrust law, but the suit was dismissed. Why have insurers been resisting clinically integrated networks?
Marty Manning: The clinically integrated network brings together a large group of providers contracting for care. Some insurers have called this arrangement a cartel, which would be illegal under federal antitrust laws. But the federal government has carved out an exception for groups that are clinically integrated, sharing clinical resources to improve patient care. The United HealthCare lawsuit was dismissed in arbitration in 2005 and we are in the middle of a four-year contract with United HealthCare.
Q: How does a clinically integrated network function?
MM: A central function is the patient registry. There are patient registries for a number of conditions, such as diabetes. Physicians report all their diabetics into the registry and we keep track of those patients, applying evidence-based medicine. Physicians and staff apply nine "measures of control," including process measures such as making sure they have an annual hemoglobin test. We started with 36 measures and now we have 116. Through our value reports on the Advocate website, we can show that this system reduces costs and improves quality of care.
Q: This arrangement also requires insurers to make additional payments to providers in the network. Why is that?
MM: There is no CPT code for operating a patient registry. An extra payment is needed to cover activities such as patient outreach and the IT functions, for example. This work is not recognized in a fee-for-service model, but we can demonstrate that it more than pays for itself.
Q: What role does healthcare IT play in these networks?
MM: You do need good IT, but this doesn't have to be daunting. You don’t need to start with a full-blown electronic medical record. You need to stat with a disease registry. You need the registry to tell you who are the patients with a particular condition, such as diabetics, and attribute them to a certain physician.
Q: What level of participation do you have among physicians on staff?
MM: About two-thirds of the medical staff at Advocate hospitals participate in Advocate Physician Partners, and about a quarter of those participants are our own employed physicians. Some of those who don’t participate have privileges at other hospitals and therefore cannot be fully committed. The rest are either not interested or don’t meet our requirements. We have 16 requirements, including board certification, high-speed internet access in the office and willingness to use computerized physician order entry at the hospital.
Q: What is the most challenging part of this for physicians?
MM: The challenge is adapting to the culture, which is one of cooperation and participation. This is not the old world of physicians versus the hospital. Both sides have to be partners now. They have to be really committed to the process. As you can tell by our membership numbers, most physicians want to join. That's because this organization is physician-driven. Physicians develop the guidelines. Most physicians accept evidence-based guidelines.
Learn more about Advocate Physician Partners.