Messenger Model Contracting
How will HAPN function initially?
In
the short-term while HAPN develops its Clinical Integration (“CI”)
program, HAPN will offer the services of its provider network, on a
non-exclusive basis, to Managed Care Organizations (“MCOs”) utilizing a
“messenger model” arrangement for purposes of contracting with those
MCOs. Under this arrangement, HAPN may not negotiate the rates on behalf
of independent voluntary HAPN providers. Rather, HAPN is a conduit of
information between the MCOs and HAPN providers to streamline the
contracting process, obtaining from MCOs contract offers, including
price and other terms, and transmitting to Provider those offers. HAPN
will maintain the confidentiality of rate information received.
MCOs
are free to accept or reject these minimum rates or propose alternative
fees. Individual HAPN providers must make their own decisions about
whether to accept or reject an MCO offer, independent of whether other
HAPN providers will accept the offer and independent of any influence or
view of HAPN. HAPN will not negotiate fee for service contracts unless
and until the CIN and its participants are financially or clinically
integrated as required by law. The initial focus will be on shared
savings opportunities through which CIN participants will be able to
earn compensation in addition to their regular fees by providing high
quality care and reducing the total cost of health care services
incurred for a population of patients.
What if I want to leave HAPN?
You may terminate your participation in messenger model contracting
after signed Participation Agreement has been in effect for at least one
(1) year, with at least 90 days advance written notice to HAPN.
About Clinical Integration
What is Clinical Integration?
Clinical Integration may be broadly defined as the coordination of care
across people, functions, activities, processes, and operating units to
maximize the value of services delivered. A clinically integrated group
of otherwise independent providers may contract together with payers if
they meet certain conditions, including having a common set of clinical
guidelines, a common information technology platform for sharing of
clinical information, performance monitoring, and performance
incentives.
What will a Clinically Integrated network look like?
CI can involve integrated health care provider networks or
independent practitioners and facilities that join together to create a
program, allowing them to:
- Identify and adopt clinical protocols for the treatment of particular disease states
- Develop systems to monitor compliance with the adopted protocols on both an inpatient and outpatient basis
- Collaborate to encourage compliance with performance improvement processes and protocols
- Enter into shared savings initiatives, care management fees, and
other contractual arrangements with health plans in a way that
financially recognizes the providers’ efforts to improve healthcare
quality and efficiency.
Is Clinical Integration just another new “buzz word”?
The complexity of healthcare and the unsustainable cost of care have
caused both government and private payers to look for new models of care
that address increasing value. They are looking to integrated delivery
systems that apply population management, eliminate duplication through
integration, encourage partnerships among providers, and reward them for
improving quality, outcomes, and efficiency. CI is commonly implemented
with primary care physicians (“PCP”), physician specialists, and health
systems working together; using proven protocols and measures to
improve patient care. CI is designed to respond to market dynamics,
which are demanding the following changes in how healthcare is
delivered:
- Demonstrate improved clinical outcomes and evidence-based care for patients
- Enhance the coordination of care between physicians, hospitals, and other healthcare providers
- Assist with quality reporting and performance
- Facilitate the delivery of the right care, at the right time, in the right setting
- Reduce healthcare costs for patients, employers, and health plans
- Improve reimbursement through demonstration of quality and cost improvement
Do government regulatory agencies permit contracting for a Clinically Integrated network?
Antitrust law makes it illegal for independent practitioners to
negotiate jointly with health plans unless they are financially or
clinically integrated. The government views CI as a way for providers to
maintain organized processes to improve the quality of medical care and
to control the overall cost of care through increased efficiency and
reduction in the amount of unnecessary care provided. An effective CI
program contains initiatives that:
- Provide measurable results which are used to evaluate provider performance
- Result in concrete remediation of substandard performance
Why does Clinical Integration work?
With CI, a comprehensive network of providers is equipped with the
technology, education, and appropriate resources to demonstrate value to
the market. The network has the critical mass to manage and improve
quality of care for populations as well as individuals through improved
access, coordinated care, improved efficiency and lower overall costs of
care.
Is Clinical Integration already taking place around the country?
Yes. Providers throughout the country are currently demonstrating
meaningful results as part of their CI programs. They have shown their
ability to improve the patient’s healthcare experience through greater
coordination of care; they have reduced hospital admission and
readmission rates, they have expanded access to primary care, and have
begun to tackle population health.
In addition, CI can help us attract and maintain new market share in a
rapidly evolving commercial insurance market. The trend is “value
network” insurance plans, which offer a lower premium payment in
exchange for access to a limited network of physicians and hospitals.
Enrollees in such plans must stay within the network. The ability to
manage costs and control utilization within a clinically integrated
network is attractive to plans building these narrow networks.
Is Clinical Integration good business?
Increasingly, providers will be asked about their ability to demonstrate
value. Independent practitioners operating their own practices may not
have the business scale or capacity to achieve alone what CI allows
collectively. CI will allow the organization under which clinical
programs are developed, clinical metrics selected, cost savings
demonstrated, management of chronic patients improved, communication
among providers enabled, and group contracting established to provide
gain share for the participation. CI providers will work more
collaboratively and be able to position themselves at an advantage in
the market based on the value they bring to payers and employers.
How does the Supreme Court decision impact HAPN’s plans for clinical integration?
The decision to uphold the individual mandate on health insurance
coverage will increase the number of insured, which should translate
into less uncompensated care and self-pay patients. To be successful,
providers must form and respond as a network to the call by the federal,
state and commercial payers for an integrated model of care and prepare
to move to these value based reimbursement models. This is the right
strategic direction for HealthAlliance of the Hudson Valley Health
Systems and its affiliated physicians and facilities to pursue together.
Clinical Integration at HAPN
Will participation in Clinical Integration require providers to change the way they practice?
Yes. Depending on current practice processes; Providers and their office
staff will have to participate in the quality and care management
initiatives that are developed to improve patient care and increase
efficiency. Ancillary, to HAPN’s primary goal of improved patient care,
is that participating providers will benefit financially for achieving
performance standards negotiated in CI contracts with payers. The amount
of incentive payments will likely depend on both the provider’s
personal score and the overall score of the organization. This latter
component highlights the importance of providers working together in an
interdependent manner to improve care.
Who creates the clinical guidelines?
The current plan is for the physicians who participate in the Clinical
Integration sub-committee of HAPN’s Board of Managers to be responsible
for HAPN’s development of clinical guidelines. We expect that that
sub-committee will review and approve the use of local and nationally
developed evidence-based guidelines and measures. The sub-committee may
also choose to develop additional guidelines with the input of
physicians in the appropriate specialties.
Will participating providers be required to refer within HAPN’s network?
The expectation is that once CI is achieved, providers will want to
refer patients to other providers participating within the network
whenever possible. This will ensure that patients cared for by
participating providers receive the evidence-based care recommended by
the physician-led CI committees. Referring within the network also
ensures that relevant clinical data is available at the point of care
and reduces unnecessary utilization of services. Of course, given
clinical need, physician and patient choice, there will be circumstances
when a referral within the network is not possible.
How can PCPs partner with specialists and hospitals?
PCP services have been undervalued in the past and poorly reimbursed
relative to specialist and procedure oriented services. PCPs have been
valued by specialists and hospitals they work with primarily for the
referrals and admissions they can generate. Specialists have been valued
by hospitals for the high revenue procedures they performed in
hospitals. The value provided by PCPs for keeping patients healthy has
previously had negative economic value for the volume-driven healthcare
provider orientation of the past several decades. We as a society have
begun to realize that there is a limit to the financial resources we are
willing to invest in healthcare without demonstrable improved patient
outcomes and reduced cost.. PCPs are beginning to be valued for what
they can prevent.
What clinical specialties will be needed by the CI network?
A broad spectrum of specialties is essential for a CI network to be able
to contract effectively and to be successful in managing care. While
any CI network will need to refer out for services not provided by its
member specialists or facilities, the more inclusive the network, the
better care can be coordinated through communication and sharing of
responsibility across specialties and care settings.
Will PCPs who refer to me but are not part of the medical
staff at HealthAlliance of the Hudson Valley be able to participate in
the network?
Being a member of the medical staff at a HealthAlliance of the Hudson
Valley hospitals is a condition of participation within HAPN, but there
are participation opportunities for medical practitioners who are
credentialed by a recognized credentialing body and approved as a
participating medical practitioner by the Board of Managers.
Will HAPN enter into risk contracts with payers?
No, it is not anticipated that HAPN will initially enter into risk
contracts with commercial or governmental payers. HAPN will pursue fee
for service contracting, and under clinical integration, will seek
alternative reimbursement in addition to fee for service, such as pay
for performance, shared savings and incentives for demonstrating
quality. Contracts that may involve downside risk would only be
entertained as HAPN develops the expertise and clinical performance
measurement capacity necessary to achieve success under such an
arrangement. HAPN’s sub-committees and board would evaluate the ability
and desire to enter into such contracts in the future.
Membership and Benefits
What makes HAPN different from other IPA’s?
HealthAlliance of the Hudson Valley has embarked upon a number of
integration and quality initiatives that will serve as the building
block to differentiate HAPN from others in the Hudson Valley. The
medical village initiative, the introduction of a Crimson Quality
Reporting Program (CQR) for the sharing of patient data, and the
development of clinical guidelines for quality measurement and
improvement are a few such efforts. HAPN is committed to moving to a CI
model; our work to date helps lay that foundation.
Can I join other IPAs?
The agreement is a non-exclusive arrangement between providers and HAPN.
Participation within the HAPN network does not preclude providers from
contracting with, or participating in, any other physician hospital
organization, independent practice association, or other organization;
provided, however, that provider’s participation in any MCO Contract
shall take precedence over provider’s participation in any other
network’s or provider organization’s contract with the same MCO.
How much does it cost to join HAPN?
At this time there are no monetary costs associated with participation
in the HAPN network. Any changes would require HAPN’s sub-committees and
board to evaluate and approve. Physician engagement, commitment to
quality improvement practices and organizational leadership is the most
important and influential contribution.
How do I join HAPN?
Providers wishing to join HAPN will complete and sign an application and
the participation agreement, then return them to HAPN for processing.
What services will HAPN provide?
- Serve as a central point of communication, information and resource to participating providers.
- Aggregate and share patient health data among providers through a health information exchange.
- Measure with electronic tools the quality and efficiency of the
participating providers across the ambulatory and inpatient
environments.
- Provide clinical decision support to proactively reach out to members in need of care.
- Once clinically integrated, negotiate with payers on behalf of HAPN providers.
- Explore with payers alternative reimbursement programs,
including pay for performance, shared savings, program development
funding, and methods to recognize care coordination activities.
What does joining HAPN mean for my practice?
In joining HAPN, providers will commit to adhere to the requirements of
the participation agreement. These requirements include, but are not
limited to, following evidence-based clinical guidelines adopted by
HAPN, sharing electronic patient data with HAPN to facilitate quality
benchmarking and measurement; and participating in continuing medical
education for providers and staff.
Must all the physicians in my practice join HAPN?
Voluntary independent physicians in a group practice are not required to
join HAPN when others in their practice elect to join, at least not
initially. Ideally, as we move toward CI, it will be beneficial to have
all providers in a practice participate, recognizing the value of an
integrated model and leveraging tools to reduce practice variation.
Will providers who are members of my practice group, but not on the medical staff, be able to join HAPN?
All HAPN participants must meet eligibility requirements, including
medical practitioners who are members in good standing of the medical
staff at HealthAlliance of Hudson Valley (HAHV), or who are credentialed
by a recognized credentialing body and approved as a participating
medical practitioner by the Board of Managers based on their provision
of clinically integrated services with other participating providers in
HAPN CI Program.
What if I already participate in a managed care organization (“MCO”)?
Existing MCO contracts in which you currently participate likely
reimburse you on a fee-for-service basis. In the coming years, we
anticipate movement away from fee-for-service reimbursement into
value-based payment. We believe working in a collaborative manner as a
group of providers best prepares you for the future.
What if I want to leave HAPN?
Under CI you may have to continue to participate in certain payer
contracts for a given amount of time or until the end of a contract
year, but that would be determined based on the terms of the payer
contract.
Can Clinical Integration impact reimbursement to providers?
Yes.The result of this demonstrated value to payers in the market often
creates economic benefits to all parties that otherwise would not be
lawfully permitted, such as the distribution of shared savings.
What is the benefit for practitioners in partnering with a hospital system?
Most practitioners are in small, unaffiliated practices. As such, they
will have limited ability to affect cost, quality, and outcomes and
therefore, will be unable to show value to the payers. If the hospital
system and practitioners share the same vision, partnering with a
hospital can provide distinct advantages. The hospital system can
provide structure and financial backing required to get the network
started and to help implement programs. These efforts demonstrate to
payers, and to the community as a whole, that HAPN is both bona fide and
valuable. Integrated networks can provide individual and small groups
of practitioners with the tools and organization needed to support their
practice. It should also be mentioned that achieving the best quality
of care for a population cannot be done solely on either the outpatient
or inpatient side.
Will employed physicians be members of HAPN?
Yes. The hospital employer will likely execute a single signature
participation agreement for all its employed physicians. Employed
physicians will also be eligible for HAPN Board seats and committee
membership. They will be full members of HAPN and full participants in
the CI program and included in CI contracts with payers.
Information Technology ("IT")
Do I need to have an electronic health record (“EHR”) system in my office to join HAPN?
No. Not at this time, but you will need to have high speed internet in
all offices to access Crimson Quality Reporting Program (CQR) used by
the network to share information on patients and on performance.
Practices are encouraged to implement an EHR before the federal
penalties regarding meaningful use of EHR and Centers for Medicare &
Medicaid Services (“CMS”) reimbursement come into play.
How will HAPN help providers with information technology?
Clinically integrated organizations not only follow standard clinical
guidelines for service and treatment, but also have a reliable means of
ensuring physicians have up-to-date, relevant clinical information on
their patients. Crimson Quality Reporting Program (CQR) provides
physicians with a powerful toolkit to enhance patient care. CQR will
provide visibility into nationally accepted physician quality metrics
including PQRS, ACO, and HEDIS-like measures. Additionally, CQR will
establish data extraction feeds, calculate selected metrics, and aid in
supporting quality reporting measures provider may have to furnish to
ensure compliance with regulatory requirements.
Will the HealthAlliance Physician Network (HAPN) Provide CQR Software and Support?
Physicians employed by a HealthAlliance of the Hudson Valley hospital
may already be using the Paragon EHR, and those systems will be
connected to the Crimson Quality Reporting Program (CQR) as part of our
investment in CQR.
For independent physicians who already use other electronic health
records, there will be a means by which those EHRs will be connected to
CQR, making data available. For those independent physicians who do not
already use an electronic health record, there will be options available
to choose and implement a method that can connect to CQR. Details on
the process for these connections and systems will be made available
through HAPN.
What data will HAPN collect and how will it be used?
HAPN will collect registration information to manage the provider
membership of the organization and to coordinate credentialing.
Clinical data associated with key measures that HAPN will use to
demonstrate clinical value and efficiency will be gathered and
aggregated. This data will also enable clinical decision support tools,
performance reporting and calculation of potential distributions through
pay for performance or shared savings programs.
This data sharing approach puts network wide information in the hands of
the organization that represents you so HAPN may effectively
demonstrate quality and value. It will enable HAPN to give you feedback
and tools, and to identify opportunities for quality improvement and
efficiency.