HealthAlliance Physician Network

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?

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.