Frequently Asked Questions about Clinically Integrated Networks and the PA Clinical Network

CINs are generally formed by independent healthcare providers, who work together with health insurers and self-insured businesses to achieve higher quality, increased efficiency and a better care experience for patients. A physician-led CIN is made up exclusively of physician-owned practices that work together to scale resources for better patient care while simultaneously maintaining their autonomy.

Pennsylvania healthcare is being carved up, forcing physicians and their patients to choose sides between large insurers in alliance with large hospital organizations. As value-based care arrangements grow, the Society is aware of reports that independent physician practices are being forced into take-it-or-leave-it contract terms using opaque measures that can commoditize physicians and fail to account for patient preferences. On behalf of those patients, the members of the Society are concerned that the promise of value-based care will be squandered and it chose to sponsor the creation of a physician-led CIN.

The purpose of a CIN is to create an infrastructure through which independent providers can work together to improve the quality and efficiency of care. A participating practice will continue to bill and collect for services under its existing payer contracts and will remain responsible for its practice’s operations. Other than claims data, participating physicians will not be required to share financial information with the CIN.

Yes. IPAs like MGP that serve as conduits (messenger model) for disseminating managed care contract terms to their members do not directly negotiate contracts with payers. As such, physicians who are members of messenger model IPAs can participate in the PACN.

No. For the 40% of Pennsylvania physicians who still own and run their practices, the expansion of value-based care is a significant opportunity to serve their patients and receive appropriate recognition for their work-effort. While the consolidation of healthcare in Pennsylvania continues, the provision of value-based care contracting has only just begun.

Physicians succeed in value-based care when they can manage the health care needs of a critical mass of one or more insurers’ population of “covered lives”. As the number of covered lives cared for by a CIN linearly increases, the ability to achieve statistically significant and clinically meaningful outcomes increases geometrically. While some larger physician groups in Pennsylvania have independently had some success with as many as 70,000 covered lives, value-based contracting based on more than 100,000 covered lives is well within reach and far more likely to succeed. And that’s just for starters.

No.

CINs led by physicians have a remarkable track record of success, according to numerous peer-reviewed reports as well as the experience of doctors in settings that are similar to yours. Once the information technology and care management systems are made available to doctors through a CIN, physicians have proven that they are the healthcare professionals best suited to reconcile quality, cost, patient satisfaction, patient preferences, risk, and uncertainty.

Even if you are getting some value-based care payments, you are being significantly underpaid. Only a small percentage of the funding being directed by government and businesses buyers toward the achievement of value for insured populations is making it to the physicians, and is insufficient to support clinical programs to promote wellness, prevent disease or reduce complications from chronic conditions. In addition, there are troubling reports from across Pennsylvania that suggest that many value-based payments are often based on faulty measurements that tend to underestimate true physician performance. The PACN will provide for timely information to drive clinical decision-making and better outcomes.

No. The physicians of a CIN should only agree to a value-based contract if it is to the advantage of the patients and all the physicians who care for them. In other words, your and your colleagues’ contracts are a floor, not a ceiling.

Yes. A patient can only be in one insurer’s value-based arrangement at a time. In addition, patient outcomes – which are the basis of value-based care – are generally tracked through a single primary care provider.

As a result, it is possible for a physician’s patient population to be engaged in two or more value-based care arrangements that have been negotiated by two or more CINs, so long as each patient is only attributed to a single VBC contract that can be tracked back to a single primary care provider. Specialist physicians have more leeway in participating in multiple CINs.

Yes. Each practice (Tax ID) will sign a group agreement and individual physicians and non-physician providers within the group need to sign an individual practitioner participation joinder to the group agreement. The group will be responsible for its activity as well as the activity of the individual practitioners.

No.

No. The healthcare needs of a covered population will always be dominated by high-cost services. Until a network manages and measures tens of thousands of patients, meaningful and measurable shifts in quality, utilization and satisfaction won’t become apparent. This “Law of Large Numbers” has been successfully used by insurers for decades. With a CIN, the physicians now can use this “Law”, especially if the network can shift patients toward hospitals and other care providers that share in the PACN’s interest in value.

It’s not the number of physicians, but the number of covered lives. The Pennsylvania Medical Society’s economic modeling suggests 20,000 covered lives is a good beginning, that 50,000 is likely to succeed and that more than 100,000 will be sustainable for years to come. We believe a statewide physician-led CIN has the potential for even more covered lives.

Successful CINs generally run a ratio of 40% primary care (including women and children’s services) to 60% specialty care. The role of the specialists is critical. A high performing CIN welcomes the inclusion of specialist physicians who share in the primary care physicians’ interest in reconciling quality, cost, satisfaction, and patient preferences. Some insurers in Pennsylvania are interested in pursuing specialty “bundles,” which may be another opportunity for the PACN.

They are cost centers to be managed.

Care management is a team-based approach to care that extends the clinical reach of physician-led care outside of the clinic or bedside setting into the community, and is typically provided by credentialed non-physicians, such as nurses. Ample evidence suggests that when care management is paired with physicians, patients are more likely to engage in their care, better manage their conditions, use their medications more wisely and rely more on their trusted physicians. It is a building block of all successful CINs.

Unlike EHRs and health insurer’s claims systems, population health information technology can honor HIPAA while simultaneously extracting, assembling, sorting and presenting actionable information to physicians and their care management teams, using metrics that are driven by patient need and physician specifications across all insurers. This not only gives a real-time snapshot of a sub-population’s health status (e.g. how many patients with a particular disease have a particular level of control) but offers “drill down” capability to find which individuals are at greatest need. Because this technology reconciles multiple data feeds from multiple sources – including the physicians’ EHRs – it can provide auditable evidence of quality. In other words, physicians will no longer have to take the insurers’ word for it. Based on quality, cost and willingness to put some of their fees at risk, we have chosen HealthEC as our population health solution.

The physicians will govern the PACN. Decision-making boards and committees comprised of participating doctors will make the quality, funds flow, credentialing and contracting decisions. A subsidiary of the Medical Society will provide the needed administrative support.

In addition to being able to deliver value for tens of thousands of patients, CINs also rely on single signatory authority. This means that participating physicians must allocate decision-making to their chosen peers and then abide by the decisions of their boards and committees.

And, while we strongly believe that we can generate value-based income for physicians in the PACN that is far in excess of the cost to participate, no one can guarantee results.

Call Keith Taylor, Director of Business Development, (814) 360-6622.