Q. What is “Clinical Integration”?
A. Clinical Integration is a structured collaboration between employed and independent physicians and hospitals to develop active and ongoing clinical initiatives designed to improve the quality and efficiency of health care services. Participation in such clinical integration creates a high degree of interdependence and cooperation among participants and allows them to jointly contract with fee-for-service managed care organizations in order to accelerate these improvements in health care delivery.
Q. What are the characteristics of effective clinical integration initiatives?
A. An effective clinical integration program contains authentic initiatives that involve all physicians committed to a common and broad set of clinical initiatives that are likely to:
- improve the health of a community
- provide measurable results in quality improvement, efficiency of care, and patient safety which are used to compare physician performance, which results in quality improvement
Q. In “real life” what does a clinically integrated network look like?
A. Clinical integration involves both employed and independent doctors on the medical staff of the same hospital or an integrated healthcare system who join together in a network that allows them to:
- identify and adopt clinical protocols for the treatment of particular disease states
- develop systems to monitor performance against adopted protocols in the inpatient, outpatient, and office based settings
- collaborate with the hospital to encourage compliance with inpatient performance improvement processes and protocols
- enter into physician-directed “pay-for-performance” and other contractual arrangements with health plans that value physicians’ efforts to improve health care quality and efficiency
Q. Why are physicians across the country engaging in clinical integration?
A. Physicians have numerous and overlapping motivations for joining together in clinically integrated networks, including:
- enhancing the quality of care provided to patients
- negotiating with payors as a CI network
- responding to health plans that are under tremendous pressure to use “report cards” that exclude “inefficient” physicians
- providing access to technological and quality improvement infrastructure that will allow physicians to accurately measure, analyze, and evaluate physician performance
- allowing networks of physicians and hospitals to market themselves on the basis of higher quality
Q. At Ochsner, will physicians be involved in the development and leadership of a clinically integrated network?
A. Yes. Ochsner and a number of physician leaders have been actively engaged in the process of developing a clinically integrated physician network known as Ochsner Physician Partners, LLC (“OPP”). This physician network is governed by a board of directors and an operating committee led by physicians, and will operate for the explicit purpose of developing and implementing a clinically integrated network. The network will negotiate “pay-for-performance” arrangements between health plans and Ochsner facilities to share in the savings generated by improving quality and reducing costs.
Q. What will the governance model be? How will physician interests be protected?
A. The Board of Directors of OPP is composed of physicians, Ochsner executives and community leaders. The board delegates much of the responsibility to the OPP Operating Committee. The OPP Operating Committee consists of 16 Ochsner and independent physicians, which include primary care and specialists from various geographic areas served by OPP.
Q. If I join OPP, will my current commercial contract rates go down?
A. The OPP approach with commercial payors will be to negotiate a pay for performance, quality element in addition to the fee-for-service (“FFS”) base payment rate over time.
Q. If I join, will OPP change how my practice operates?
A. Independent physicians will maintain their practice identity, existing staffing model, and other office practices as they see fit. Partnership will require a commitment in terms of time and accountability for compliance with OPP’s clinical initiatives stipulated by the network negotiated contracts.
Q. How will I get paid for achievement of quality measures?
A. Physicians will continue to practice under a FFS arrangement for all non-network contracts. Depending on individual performance related to the quality metrics approved by the Operating Committee, physicians will be eligible for performance incentive payments made to their medical practice. The medical practice may decide to pass this bonus directly to the individual physician members or may elect a different method of distribution based on the practice(s) policies and guidelines.
Q. When will I get paid if the performance target is met?
A. The earned performance payments vary by payor and will be made within 3-4 months following the end of the performance improvement cycle. The payment log is required in order to review and audit the performance reports and assure that the accounting and performance incentive payments are accurate and complete.
Q. What will physicians need to do in order to participate in OPP?
A. Physicians will be asked to do the following:
- Accept the invitation to join Ochsner Physician Partnership.
- Sign a Network Participation Agreement and a Business Associate Agreement.
- Commit to collaborate with the network in the development and adoption of clinical initiatives that will enhance the quality, service, and cost effectiveness of patient care.
- Hold themselves and each other accountable for the adherence to clinical initiatives, including specific performance improvement efforts should physician(s) not meet the benchmarks set by the network and payor contracts.
Q. By agreeing to participate in OPP, will physicians be required to abandon medical staff appointments at non-Ochsner hospitals or admit patients only to Ochsner hospitals and ambulatory care facilities?
A. No. OPP is a non-exclusive organization, making no limitations whatsoever on a physician’s ability to admit patients to non-Ochsner sites of care.
Q. What clinical initiatives will OPP Include?
A. As an OPP member, you will be strongly encouraged to become an active participant in an OPP committee designed to improve the clinical outcomes of the Ochsner clinical integration network, such as:
- Care Coordination
- Chronic disease management
- Generic drug use
- Electronic Medical Record “”EMR”) adoption
- Hospital Efficiency Programs: Pursuit of Value
The goals of these clinical initiatives is to enhance the value of the services provided to patients 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 benefits systems, and hospital and ambulatory EMR systems.
Q. Will participation in OPP require physicians to change the way they practice medicine?
A. Yes. Participation in the quality and care management initiatives of OPP will require focused time and attention from physicians and their office staff. In return, Ochsner partnering physicians will be eligible to obtain financial rewards for their performance, funded by contracted health plans. The amount of performance incentive payments will depend on both the physician’s personal performance achievement and the overall performance of the network. This latter component highlights the importance of physicians working collaboratively as one network to improve the care of every patient we serve.
Q. What role does an EMR play in clinical integration?
A. An ambulatory EMR is not a prerequisite for the development of clinical integration. While a common EMR across all participating physician practices can certainly accelerate and strengthen a clinical integration program, many successful models of clinical integration nationwide do not depend on a sole ambulatory EMR for data on physician performance. OPP has implemented an EMR that is designed to capture and extract the data necessary to continue to operate this clinical integration program. One opportunity offered by OPP is the ability of the health system to underwrite a physician office EMR. Each network practice is required to formulate a plan to direct its claims data, clinical data, existing hospital data, disease registries, and/or chart audits to the network’s data warehouse.
This practice data is critical to the networks ability to measure, analyze, evaluate and report physician performance to the networks payors.
Q. Has the Federal Trade Commission (FTC) adequately clarified the meaning of clinical integration?
A. Since 1996, the FTC has been very consistent in its definition of clinical integration as well as the analytical framework it applies when evaluating clinical integration among a network of independent physicians. As defined by the FTC, a “qualified clinically integrated arrangement” is:
….. an arrangement to provide physicians services in which: 1) all physicians who participate in the arrangement participate in active and ongoing programs of the arrangement to evaluate and modify the practice patterns of, and create a high degree of interdependence and cooperation among, these physicians, in order to control costs and ensure the quality of services provided through the arrangement; and 2) any agreement concerning price or other terms or conditions of dealing entered into by or within the arrangement is reasonably necessary to obtain significant efficiencies through the joint arrangement.
The FTC has also indicated on numerous occasions that clinical integration programs may include:
…..(1) establishing mechanisms to monitor and control utilization of health care services that area designed to control costs and assure quality of care; (2) selectively choosing network physicians who are likely to further these efficiency objectives; and (3) the significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies. (Statement of Antitrust Enforcement Policy in Health Care by the FTC and the U.S. Department of Justice, Statement 8, August 1996).
Q. How is it lawful for a network of clinically-integrated physicians to collectively negotiate with health plans when the FTC is actively investigating and prosecuting physician networks for negotiating PPO contracts?
A. The FTC views clinically integrated physician networks as an opportunity to create efficiency and quality in care that outweighs any restraint on trade. However, the FTC will continue to monitor those networks that fail to demonstrate the elements of true clinical integrations.
Q. What benefits do health systems provide in the development of clinical integration programs?
A. Partnering with a health system can provide distinct advantages to a network of independent physicians in the development of clinical integration. When health systems share the same quality vision as the physicians, the health system can be a powerful ally in program development by:
- collaborating with the physicians in the development of clinical integration initiatives based on existing inpatient quality measures
- providing financial assistance and personnel in the implementation of inpatient and outpatient initiatives that provide true community benefit and are not tied to the volume or value of referrals
- demonstrating to payors and the community as a whole that the clinical integration program is both legitimate and valuable
Q. Why should Ochsner and its affiliated physicians believe clinical integration to be a good business and health care strategy?
A. Doctors and health systems nationwide are developing clinical integration programs because they believe in the value they will create for the patient, provider, and payor:
Clinical integration allows physicians to:
- demonstrate their quality to current and future patients
- choose the clinical measures against which they will be evaluated
- enhance revenue through better management of chronic patients
- gather collective support for building necessary infrastructure
- engage in group contracting
Clinical integration gives health systems the ability to:
- 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
- develop a better, more collaborative relationship with their medical staff
- improve performance on hospital pay-for-performance measures
- position themselves in the market on the basis of higher quality
- effectively manage patient populations in the communities we serve
Clinical integration provides patients with:
- higher value for their health care dollar
- effective care management and outreach from a trusted source, their selected physician
- reliable information to support their choice of health plans, physicians, and hospitals
- accurate and meaningful provider ratings
- greater stability in their relationship with their doctor and hospital
- less likelihood that they will need to choose new health care providers every year
Clinical integration gives employers:
- the ability to effectively manage the health care costs of employees and their dependents through the purchase of better, more efficient health care services
- increased employee productivity and reduced absenteeism, through improved management of chronic diseases
- lower health care costs over the long term, through the reduction of variation in physician practice patterns
- reliable information to support conversion to consumer-driven health insurance products
Q. How can I receive more information regarding the details of Ochsner Physician Partners?
A. A document that describes the benefits and requirements of membership is available for your review. A Participation Agreement can be provided for your review along with your acceptance should you want to join Ochsner’s Clinical Integration Network, as an Ochsner Physician Partner. At any time, you are encouraged to contact Ochsner Physician Partners at 504-842-2096 or firstname.lastname@example.org to further discuss this opportunity.