Doctors Find Strength in Numbers Through Clinically Integrated Networks

By Lola Butcher
May 1, 2017

Throughout the country, these physician-led organizations are taking the lead in improving the value of health care. Here’s how some of them are doing it.

Across the southeastern United States, a dozen health systems that include more than 50 hospitals and 3,500 clinicians in some 235 practices are coalescing as a physician-led network.

In Michigan, 28 hospitals and a dozen large physician organizations are operating as a statewide clinically integrated network owned by three health systems.

And in Texas, more than 1,100 independent physicians are organizing a clinically integrated network that is unaffiliated with any hospital.

While the scope of their efforts varies, each of these physician-led networks — like a growing number of others across the country — is trying to solve one of health care’s biggest problems: a fragmented delivery system that results in poorly coordinated care, high costs, patient frustration, clinician burnout and poor health outcomes relative to other developed nations. It’s a big job. But their leaders believe the clinically integrated network is essential to achieving health care’s Quadruple Aim: better patient experiences, better population health, better cost controls, and a better work life for physicians and other clinicians.

If they’re successful, they will distinguish their organizations in the marketplace and, more important, do their part to help fix some of the dysfunction in health care.

Here’s how they’re doing it.

A Regional Approach

The Vanderbilt Health Affiliated Network is concentrated in Tennessee but extends into Georgia, Alabama, Mississippi, Arkansas and Kentucky. The network was started by Vanderbilt University Medical Center and four other Tennessee health organizations in 2012.

CIN INS AND OUTS

New payment systems, such as accountable care organization contracts and bundled payments, reward health care providers that improve care coordination. Not surprisingly, most provider organizations are looking for a way to do just that.

The most common strategy is consolidation. The central idea is that hospitals and physicians with common ownership will be aligned administratively and financially, smoothing the way for clinicians to share patient data and coordinate care efficiently.

That has prompted numerous mergers and acquisitions in recent years. But it’s something of a fantasy, says Kenneth W. Kizer, MD, MPH, founding director of the Institute for Population Health Improvement for the UC Davis Health System in California.

“Consolidation is not the only approach, and often it is not necessarily the best approach,” says Kizer, who, as an undersecretary in the U.S. Department of Veterans Affairs, was responsible for running its health care system from 1994 to 1999. The effort needed to merge organizations financially, administratively and culturally can distract from the work needed to effectively integrate clinical operations, he says.

During his VA tenure, Kizer saw firsthand that unified ownership does not equate to well-coordinated care delivery. To reduce fragmented care within the VA system, he reorganized clinical operations into networks that functioned similarly to today’s ACOs, introduced a systemwide performance management system and launched the biggest electronic health record deployment in history.

Based on his experience, in a 2015 article for the Journal of Healthcare Management, Kizer identified seven key abilities and characteristics needed to integrate patient care in actual practice:
  • A shared vision of health care delivery.
  • Governance that sets goals, policies and procedures needed to coordinate care across the continuum.
  • Strong clinical leadership.
  • Information management tools and other infrastructure needed to support clinical integration.
  • Team-based care.
  • The ability to measure and monitor clinical performance.
  • Shared financial risk and reward for clinical outcomes.

By contrast, the Federal Trade Commission has its own definition for a “clinically integrated network.” Independent physician groups, hospitals and other health care providers are prohibited from jointly negotiating payer contracts unless they share either substantial financial integration or clinical integration. To stay on the FTC’s good side and avoid antitrust issues, it says, a network must be likely to produce “significant efficiencies that benefit consumers.” Among other things, the FTC requires that a CIN monitor physicians’ performance to make sure they comply with standardized care guidelines and take remedial action if they fail to do so.

“Our intent is really to transform how health care delivery across the Mid-South occurs so that we improve the health of millions of people in the region,” says David Posch, the medical center’s executive vice president for population health. Members pay dues to support the network’s infrastructure and agree to share data, participate in quality improvement efforts and comply with evidence-based protocols as they become available. The network provides care for more than 130,000 patients, most of whom are employees or dependents of self-insured employers, including the health systems that participate in the network.

In each contract, the network earns “shared savings” based on its performance during a given period of time in comparison with that of providers in the same market who are not in its network.

“Our aim is to do a better job, both in terms of clinical outcomes and also in terms of cost,” Posch says.

For example, the network’s pediatric program saved 17 percent in comparison to the market trend in 2014. In adult services, the network and its participants also saved employer and commercial health plans about $10 million that year. By 2020, the network’s leaders expect to be responsible for at least 1 million lives.

Giants Coming Together

In Michigan, the Together Health Network was created in 2014 by Ascension, the nation’s largest nonprofit health care system, and Trinity Health, another huge Catholic system. Last year, University of Michigan Health System, one of the nation’s top academic medical centers, joined as an equity partner.

Its chief executive officer, Scott Eathorne, MD, describes Together Health as a “super CIN,” because it brings together 10 smaller networks that operate in various parts of the state. Rather than recruiting individual physician groups or hospitals to join the super CIN, Together Health developed contractual relationships with each of the 10 groups.

With a scale so large, Eathorne says his network relies on the smaller affiliates to drive performance improvement at the local level. His job is to build on their efforts by collecting and disseminating performance data with the goal of decreasing variation in the care provided.

With four payer contracts in place, Together Health aspires to contract with others that want a statewide network of value-oriented providers.

“Our vision, quite simply, is to be the preferred partner — for individual patients, for our physician colleagues and other providers, and for payers and employer groups,” Eathorne says. “We believe that, by developing care models that deliver on the Quadruple Aim going forward, we can be the recognized entity that is able to deliver on that consistently across the state.”

By contrast, North Texas CIN is composed of independent primary care and specialty physicians who believe they are in the best position to control costs and improve quality, thereby creating a sustainable health care delivery system.

“Many hospital executives think this problem is theirs to solve, but I’m not convinced of that,” says Jim Walton, DO, the network’s chairman. “I think physicians have a serious obligation to provide the leadership to create these new solutions.” The Dallas-based organization started in 2015 with a single independent physician association entering into an accountable care organization contract with a single commercial payer. In 2016, the network expanded to include two other IPAs and several independent physician groups, and added three commercial ACO contracts covering approximately 100,000 patients in the Dallas/Fort Worth area. Earlier this year, it added a Medicare Shared Savings Program contract covering an estimated 7,000 patients.

Through its multi-IPA collaboration, TXCIN has a potential membership of nearly 2,500 physicians, if all physicians were to participate. To date, almost one-third have signed a participation agreement and agreed to use a common web-enabled software product that facilitates referrals among the CIN members and reports quality and cost performance data extracted from insurance claims data.

“Independent physicians are indeed independent,” Walton says. “In north Texas, we have a fairly large number of independent physicians who are still trying to decide on this topic of clinical integration and if ACO contracts bring additional value to their practice. The obligations of being clinically integrated sometimes, in their mind, outweigh the financial benefits.”

In 2015, the first year of its ACO contract with Cigna, TXCIN earned “shared savings” because its physicians generated 7.5 percent lower costs than the overall north Texas market. Although the network is working to develop care guidelines, robust data-sharing and care coordination support for its physicians, none of those were in place in 2015.

Thus, Walton attributes the CIN’s performance to individual physicians deciding to improve the value of the care they control.

“When they say they’re in, they generally start to change their practice behaviors unconsciously,” he says. “Early success with independent physicians does not require a massive investment of IT infrastructure, but rather focused work to win them over to the idea that if you can find waste by yourself, drive it out.”

What They’ve Learned

As he continues to build Together Health, Eathorne says there’s one ingredient for success: complete transparency.

Because he works on behalf of three large health systems and their affiliated physicians, both private and employed, Eathorne and the leadership team must develop and maintain relationships that keep thousands of overburdened executives and clinicians on board as their industry undergoes major disruption.

It is not easy work to take physicians and hospitals that historically have been independent and integrate them into a common care delivery system. It is not just about wiring things together. You have to be willing to put the time and effort into this.


David Posch, Vanderbilt Health Affiliated Network

“You cannot be too transparent in the effort to build trust and a shared vision that will allow you to drive some of the changes that are required,” he says. “We know that change is everywhere and it’s putting a significant burden on our physicians. Being respectful of that and bringing them into every conversation, just to understand where folks are at and making sure that you are working toward solutions that are going to be a win for all the key stakeholders, is essential.”

For TXCIN, the aim is to help physician practices succeed. It recently hired two care navigators to work with expensive, “high-utilizer” patients — those who do not have regular access to primary-care physicians and frequently use hospitals to deal with chronic conditions — identified by payers. They connect with those patients after an emergency department or inpatient discharge, help them stay on track with their care plan, and schedule physician visits so they avoid future ED visits and readmissions.

The Vanderbilt network coaches clinicians to use pharmaceutical products that produce the best outcome for patients at the lowest cost. “Pharmacy is approaching 30 percent of the cost of insurance premiums, so that is a very important element of where we work,” Posch says. They’re also expected to work on quality improvement projects that increase the efficiency, quality and coordination of care. “We have a fairly elaborate medical director structure that meets with our practices and engages them in these efforts,” he says.

Likewise, the Vanderbilt network is creating a health information exchange that can collect and share electronic health record data among its members, allowing easy access to clinical data about patients when they move from one provider to another. “Our aim is not just to be able to exchange data, but also to embed clinical decision support into those electronic medical record systems so we provide real-time support about the best evidence-based practice,” Posch says.

It’s a similar story with TXCIN. Walton says “there’s no way on this planet” that all independent physicians will agree to adopt the same EHR system, but its members do agree to use web-based software that facilitates patient referrals and reports quality and cost-related performance data to calculate shared savings through payer contracts.

Eventually, the network will start collecting data from the clinicians’ respective EHR systems and using it in a way that helps physicians improve their practices.

“Doctors won’t do this without it being functionally relevant to their practice, so that’s where we are headed — helping them improve quality or reduce inefficiency and save money,” Walton says. “But that is going to be phase two, which is somewhere down the road.”

Patience Is a Virtue

Assembling a clinically integrated network doesn’t happen immediately, and success isn’t always quick. Posch and other CIN leaders know it takes a lot of energy to make it work.

“It is not easy work to take physicians and hospitals that historically have been independent and integrate them into a common care delivery system,” Posch says. “It is not just about wiring things together. You have to be willing to put the time and effort into this.”

YOUR TURN

What do you think about clinically integrated networks? Do you support the idea of integrative medicine, or do you prefer to remain an independent provider? We welcome all points of view. Send your thoughts to journal@physicianleaders.org to be considered for publication.

Clinical integration consultants abound, and they might be helpful with the legal aspects of qualifying as a clinically integrated network in the eyes of the Federal Trade Commission (see sidebar), but the substantive work cannot be delegated. “The real work has to come from the participants themselves,” he says. “You have to be dedicated to the idea that we must be doing the right thing for the right reason, and that sometimes will mean utilization is going to go down and that hospital demand might change as we move more care into ambulatory settings.”

As the value movement gains traction in health care, insurers, employers and hospitals in value-oriented contracts want tangible results quickly. But physicians are slow to change the way they practice.

Expecting them to come to an all-day meeting or read a memo with a long list of how-to-be-part-of-a-successful-CIN is not going to work. “They have their heads down, and they are overwhelmed with patient care,” Walton says. “That means going to them and having conversations on a 30-minute lunch break and really taking a slow and steady approach.” Payment reform initiatives require physician buy-in, and when other stakeholders push for quick changes, they often fail. “I see that the problems are so urgent that I want to race ahead, but I need to be able to get in step with them,” he says. “If I do that, we will look back after 12 months and see that we have moved the needle some, and we just need to keep doing it year after year after year.”

Lola Butcher is a freelance medical care writer based in Missouri.

Topics: Leadership Journal

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