MetroCare/HealthChoice Trilogy Clinically Integrated Network FAQs

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1 MetroCare/HealthChoice Trilogy Clinically Integrated Network FAQs 1. What is clinical integration? Clinical integration is a new model for healthcare delivery that promotes collaboration among a community s independent providers to furnish high quality and lower cost care in a more efficient manner. Physicians, hospitals, and other providers share responsibility for, and information about, patients as they move from one setting to another over the entire course of their care. Working together, clinically integrated providers develop and implement evidence-based clinical protocols, focusing on delivery of preventive care and coordinated management of high-cost, high-risk patients. Utilizing shared information technology, these providers conduct ongoing clinical care reviews to identify opportunities for improvement and ensure adherence to protocols. While the antitrust laws generally prohibit joint contract negotiations among independent providers, those laws permit clinically integrated providers to engage in collective negotiations with health plans. Working together, these providers can more effectively compete for payer contracts because they demonstrate high quality and greater efficiency in care delivery. 2. What is a clinically integrated network, or CIN? A clinically integrated network is the infrastructure needed to support clinical integration among all physicians within a community. Our CIN network, MetroCare / HealthChoice Trilogy (Trilogy), has developed a governance structure through MetroCare Physicians, Methodist Le Bonheur Healthcare and HealthChoice. MetroCare will decide on clinical protocol development and implementation, performance measurement and enforcement, and formulas for rewarding physician performance. HealthChoice will identify, implement, and maintain supportive technologies (including data analytics); analyzing care processes to identify efficiencies; encouraging patient engagement; negotiating pay-for-performance payer contracts; and distributing incentive payments to members. While a hospital can provide administrative expertise for a CIN, the network s clinical leadership is led by physicians. Only physicians have the knowledge, skill, and experience needed to achieve improvements in clinical quality and efficiency. Unlike organizations such as integrated delivery networks (solely with hospital-employed physicians) and large multi-specialty physician practice groups, which base their clinical integration strategies on economic integration, a CIN respects and preserves the economic independence of its physician members. 3. Who governs Trilogy? Trilogy is a 50/50 collaborative effort between MetroCare Physicians clinically integrated physicians and Methodist Le Bonheur Healthcare in partnership with HealthChoice. 4. What are the key characteristics of Trilogy? Well-defined governance structure to promote organizational goals while protecting individual interests. Physician-led. Data driven. Relentless focus on improving the health of the population served. Adherence to evidence-based medicine guidelines and clinical protocols. 5. Why has interest in CINs grown so rapidly in the last several months? The healthcare payment and delivery system is undergoing fundamental changes. Currently, a provider is paid for the individual services furnished by that provider. Such volume-based reimbursement offers no economic incentive for providers to work together in providing patient care. However, payers now are shifting to value-based reimbursement, i.e., rewarding providers that deliver high quality care in an efficient manner. These include, for example, the Medicare Shared Savings Program, hospital physician value-based purchasing, and bundled payments. Commercial insurers, as well as employers, also are aggressively pursuing value-based purchasing arrangements. More and more payers are introducing pay-for-performance provisions in their standard provider agreements.

2 6. How is a CIN different from an accountable care organization (ACO)? The term clinically integrated network dates back to the mid-1990s, when the Department of Justice and the Federal Trade Commission first acknowledged independent providers working together to improve quality and efficiency could engage in joint payer negotiations. The term accountable care organization was first used about a decade later in reference to a group of providers that assumes responsibility to provide care for an assigned patient population. Typically, an ACO bears some financial risk associated with providing such care. Generally speaking, an ACO is a more formal arrangement, structured to satisfy specific payer requirements. For example, only an ACO that meets certain regulatory requirements is eligible to participate in the Medicare Shared Savings Program. A CIN may elect to form an ACO for purposes of contracting with a particular payer. That decision, however, may be deferred until the CIN is fully operational. 7. How do pay-for-quality contracts and shared savings programs work? Under a pay-for-quality contract (often referred to as a P4Q contract), an individual provider continues to submit claims and received fee-for-service reimbursement. If the provider achieves a certain goal specified in the contract, the provider receives an additional incentive payment. A P4Q contract may provide for a penalty if a provider fails to meet a specified target. The Medicare Physician Quality Reporting System ( PQRS ) is an example of a P4Q program. Under PQRS, a physician will receive a 0.5 percent bonus payment if he or she submits a report on specified quality measures in If, however, a physician does not submit such a report in 2013, that physician will be penalized 1.5 percent on Medicare payments in Many commercial payers are looking to include P4P provisions in their contracts with individual providers. Generally speaking, Trilogy can negotiate more favorable P4Q terms. Also, Health Choice and MetroCare support an infrastructure that enables its members to achieve P4Q measures. Under a shared savings program, a network of providers is eligible to receive a portion of a payer s savings generated by improved quality and efficiency. This is accomplished through a multi-step process: (1) The payer contracts for a specific patient population with the CIN, and these patients are attributed to a CIN provider, the patients primary care provider. (2) Providers in the CIN continue to receive fee-for-service reimbursement for all services, including services for patients in the assigned population. (3) Trilogy negotiates a benchmark rate based on the payer s historical cost of providing care for that population. (4) At the end of the year, the Trilogy and the payer calculates the actual cost of providing care for the contracted patient population. (This includes the costs of care furnished by providers not included in the CIN. Patients in the assigned population are not limited to providers in the CIN). (5) If the actual costs of care are less than the benchmark and if specified quality measures are met, the CIN will receive a portion of the savings. If those measures are not met, the payer will not share the savings with the CIN. (6) Under two-sided shared savings programs, the CIN is liable for a portion of the difference if the actual costs of care exceed the benchmark. (7) The CIN is responsible for deciding how the shared savings (or losses) are to be distributed among its members. MetroCare Physicians, Methodist Le Bonheur Healthcare and HealthChoice will collectively make this decision. Typically, a portion of any shared savings payment is retained by the CIN to pay its expenses. 8. Are there CINs in other communities that we can use as models for our network? There is much to be learned from providers in other communities that have formed CINs. Keep in mind, however, there are only a handful of CINs that have been operating for an extended period of time. Most CINs have commenced operations only recently. There are far more communities (like ours) still in the early stages of the process. There is no one size fits all solution for clinical integration. To be successful, Trilogy (our CIN) must fit within our community s culture and values. Thus, it is critical physicians have an active leadership role and that all providers have the opportunity to participate in this planning process. The engagement of and proactive partnership with physicians is essential to long-term success.

3 9. Have other CINs been successful in improving quality and efficiency in healthcare delivery while protecting physician incomes? Early adopters have achieved impressive results. For example, you can find success stories at Advocate Health Care in Chicago, Billings Clinic in Montana, and Mesa IPA in Grand Junction, Colorado. Advocate Health Care publishes an annual Value Report (available at which clearly demonstrates the value of a high functioning CIN to providers, payers, and patients. 10. What types of protocols have other CINs adopted? Typically, a CIN develops its initial set of protocols around delivery of preventive care and management of patients with chronic diseases (e.g., diabetes, COPD, asthma, heart failure). CINs have utilized well-recognized quality standards as a basis for protocol development including, for example, National Quality Forum-endorsed standards. Other sources include CMS Physician Quality Reporting System measures, the Medicare Shared Savings Program performance standards, and Stage 1 and 2 meaningful use quality reporting requirements. In the case of Trilogy, MetroCare Physicians Quality Enhancement Committee will utilize the aforementioned protocols and ultimately decide upon the applicable physician metrics and guidelines. 11. How do CINs generate cost savings? First, adherence to CIN - approved clinical protocols and sharing of patient data eliminates unnecessary and duplicative care. A greater emphasis on preventive services saves money by avoiding more expensive care down the line. Second, a physician participating in a CIN has access to the network s care coordination services for his or her patients. This includes transitional care management as well as complex care management. A transition of care program is a set of steps designed to ensure the coordination and continuity of healthcare as patients move from one setting to another. This can include helping with logistical arrangements, education of the patient and family, and coordination among the health professionals. These programs have proven successful in reducing cost by avoiding hospital readmissions and emergency room visits. A complex care management program focuses on a small number of high risk, high cost patients. Research indicates that in most communities, a small number of patients generate a high percent of the cost. By providing intensive, personalized support for these patients that addresses their medical and psychosocial needs, costs can be significantly reduced by avoiding unnecessary treatment, hospital admissions and Emergency room use. 12. What role does technology play in Trilogy? Trilogy will employ technological solutions in several ways to advance its goal of improved population health: (1) First, technology can assist a physician in adhering to clinical protocols, such as tracking whether a patient has received certain preventive services. (2) Second, reporting on quality measures to the Trilogy network (or to payers directly) may be accomplished using IT solutions. (3) Third, data analytics can identify those patients for whom certain interventions are appropriate, thus allowing providers to manage those patients more effectively. (4) Fourth, technology can assist Trilogy in tracking care costs to identify opportunities for improvement. (5) Fifth, electronic health information exchange permits Trilogy members to effectively coordinate patient care (especially for high-cost, high-risk patients), thus improving outcomes and reducing costs. (6) Sixth, patient and family member access to electronic records enables them to be more active and engaged participants in the care process. 13. What are the network participation requirements for Trilogy? Physicians are required to have access to high speed internet, utilize electronic claims processing, have and use an active address, participate in Trilogy information session conducted by MetroCare, complete MetroCare s online health literacy, healthcare economics and network update modules. MetroCare will add additional participation requirements over time with reasonable advance notice and reasonable assistance to satisfy the requirements.

4 14. What additional expectations will there be of me as a Trilogy member? Physicians agree to cooperate with and participate in Trilogy, and to share clinical information that is necessary to administer the Clinically Integrated Program. Physicians also agree to actively participate in Trilogy development by participating in committees, contributing to guideline and metrics development, reviewing compliance with the program and/or assisting with evaluation of technology solutions. They also agree to refer to MetroCare physicians who are participating in the Trilogy unless specific circumstances require referral outside the network. The purpose of this clause is to promote integrated and coordinated care through our accountable network 15. Do all the members of my group have to participate in Trilogy? 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. 16. Can we opt out of certain Trilogy contracts? Not for commercial contracts. Unlike the messenger model, you and your entire group must participate in all the contracts with which Trilogy chooses to contract. Trilogy will only contract with plans that agree to utilize our clinical integration program and reimburse us favorably for the services that we provide. Exceptions include Medicare, Tenncare and Workers Comp contracts. 17. How does Trilogy make decisions? How do the interests of the hospital balance against those of the physicians? Trilogy s governance structure is physician-led and furthers its members common goals while protecting their individual interests. This is achieved through the selection of governing board members, balancing voting rights among participants, reserving certain fundamental decisions to the respective parties, delegating organizational functions through carefully drafted committee charters, and other organizational processes. In summer 2014 MetroCare Physicians and Methodist Le Bonheur Healthcare entered into a 50/50 CIN agreement via HealthChoice. MetroCare Physicians is the governing body for its clinically integrated physicians. 18. What services will the Trilogy provide to its physician members? The following is a non-exclusive list of services Trilogy and MetroCare Physicians provides for its members Keep in mind Trilogy does not necessarily have to provide all services directly; and may contract with third parties for specific services. Also, in the future, Trilogy may contract to provide services to third parties. This may be a way for Trilogy to generate revenue to support its operations. Support the implementation and use of the Vision Practice Support Tool, which provides member practices with population registries, performance metrics, and additional care information about their patients Support and implement evidence-based medicine practices and population health improvement strategies Provide data and analysis of cost and quality metrics for clinically integrated patients Provide chronic disease management programs, such as diabetes prevention and management, to clinically integrated patients Provide care management services for high acuity clinically integrated patients Provide transitional care management services for clinically integrated patients Pursue preferred network contracts with private payors and local employers Develop and pursue gain-sharing, shared savings, and other quality and efficiency programs with financial rewards for physicians Participate in Medicare Shared Savings Program Support primary care providers in achieving Patient-Centered Medical Home designation 19. How will Trilogy s operations be funded? Funding for Trilogy s operations is currently coming from the joint ventures two partners, Methodist Le Bonheur Healthcare and MetroCare Physicians. 20. Will Trilogy participation be open to all physicians? To ensure compliance with the antitrust laws, Trilogy participation is open to all MetroCare members and who maintain compliance with specified performance standards. Participation in Trilogy will be completely voluntary. A practice decision regarding participation will not impact his or her status as a member of MetroCare or the HealthChoice panel.

5 21. What will happen to my private practice if I join the Trilogy? The purpose of Trilogy is to create an infrastructure through which independent providers can work together to improve the quality and efficiency of care. A participating practice in Trilogy will continue to bill and collect for services under their existing payer and will remain responsible for their practice s operations. Trilogy will not purchase any physician practice. No physician will be employed by or have an independent contractor arrangement with the Trilogy as part of Trilogy participation. Other than claims data, participating physicians will not be required to share financial information with the Trilogy. (See data FAQ s) A physician s relationship with Trilogy is defined by the terms of the MetroCare Participating Group Agreement. A practice or its physicians cannot be required by Trilogy to do anything that is not specified in that agreement. Nor can the CIN take any action against a practice or its physicians that is not spelled out in that document. 22. What will happen to Trilogy participants who do not meet established standards? The implementation of clinical protocols and performance measures will be an ongoing process of education and continuous quality improvement. No provider will be expected to perform at a certain level without adequate support to achieve that goal. While the intent is to improve quality and outcome metrics, successful CINs demonstrate the will to cull an outlier if all attempts, such as peer review and education, fail. To protect individual s rights, the CIN may establish a review process to afford a physician the opportunity to challenge an adverse decision. No participant will be excluded based solely on subjective criteria. 23. Who will use Trilogy? We will initially start with marketing Trilogy to commercial health insurance carriers such as Cigna, BCBST and United who desire to offer the accountable care approach to their purchasers. If Trilogy decides to engage in contracts with Medicare or Tenncare in the future, then there will be an opt out provision for practitioners for these specific governmental plans only. 24. How will the Trilogy program continue to change over time? All Trilogy requirements regarding establishment of change to IT, payments, administrative burdens, quality metrics, performance goals or any other significant areas impacting physician practices will be made by the MetroCare Board after careful consideration, review and contemplation. No decisions can be made unilaterally by either partner. 25. I still have other questions. Who can answer them? Please visit or You may also contact Janie Jones, MetroCare Director Practice Support at janie.jones@metrocarephysicians.com