Clinical Integration
Update
Michele Madison
mmadison@mmmlaw.com
404-504-7621
Clinical Integration
• The integration of clinical information and
healthcare delivery services from distinct
entities.
• Continuum of care, including preventative,
outpatient, inpatient acute hospital and postacute care to improve the value of care provided
• Ultimately designed to achieve Triple Aim
• Improving Population Health
• Reducing Costs
• Improving the Experience of Care
Clinical Integration Models
Accountable Care Organizations
Hospitals and Physicians
Physicians
Healthcare Systems and Health Plans
ACO
• Recognized under State Law as Legal Entity with a TIN.
• Governing Body must have 75% representation from ACO
members.
• Financial and clinical integration.
• A leadership and management structure that includes
clinical and administrative systems.
“Better health care for individuals” defined as health care
that is safe, effective, patient-centered, timely, efficient,
and equitable
Georgia ACOs
• Accountable Care Coalition of Central Georgia, LLC
Accountable Care Coalition of DeKalb, LLC
Accountable Care Coalition of Georgia, LLC
Accountable Care Coalition of Greater Athens Georgia II, LLC
Accountable Care Coalition of Greater Augusta & Statesboro,
LLC
Accountable Care Coalition of Southern Georgia, LLC
Accountable Care Coalition of Western Georgia, LLC
Morehouse Choice ACO-ES
The Premier Health Care Network, LLC
Meridian Holdings, Inc.
WellStar Health Network, LLC
Accountable Care Coalition of Coastal Georgia
Accountable Care Coalition of Greater Athens Georgia
Breakdown of ACOs
Networks of Individual Practices
Group Practices
Hospital/Professional Partnerships
Hospital employing ACO
professionals
Federally Qualified Health Center
Rural Health Clinic
Critical Access Hospital
121
90
66
44
55%
41%
30%
20%
15
11
4
7%
5%
2%
Bundled Payment
1. Episode of care as the acute care hospital stay
only (Model 1),
2. The acute care hospital stay plus post-acute care
associated with the stay (Model 2),
3. Just the post-acute care, beginning with the
initiation of post-acute care services after
discharge from an acute inpatient stay (Model
3).
4. A single, prospective bundled payment that
would encompass all services furnished during
an inpatient stay by the hospital, physicians and
other practitioners.
Norman Oklahoma PHO
• 280 participating physicians and the hospitals in the
Norman Regional Health System
• Horizontal Agreements to Provide Services among
Competing entities
• Collaborative clinical activities,
• clinical practice guidelines;
• physician performance measures;
• conducting peer review and corrective action
processes, and
• designing and implementing quality improvement
initiatives
St. Lukes –Saltzer Medical
Group
• St. Luke’s . . . “are to be complimented on their
foresight and vision.”
• Acquired Physician practices and . . .
• went one too far . . .
• Provided 80% of Primary Care Providers in
Service Area
• Could have negative impact on managed care
negotiations notwithstanding the improvement
in patient outcomes
• Courts Ordered Divestiture
Lessons Learned
• Interdependence of Physicians is important
• Must include Quality Reporting/Metrics
• Independent Negotiation of Rates
• Reduction of Costs
• Joint Contracting is Subordinate
• Patient Satisfaction Improvement
Beyond Medicare/Medicaid
Third Party Payers are also supporting Clinical
Integration
BCBS partnership with Emory for ACO
Changes in the payer marketplace
United Purchases Physician Practices
Humana Purchases Concentra
Cigna Opens Alternative Physician Practices
Disclaimer
•
The materials and information presented and contained within
this document are provided by MMM as general information only,
and do not, and are not intended to constitute legal advice.
•
Any opinions expressed within this document are solely the
opinion of the individual author(s) and may not reflect the opinions
of MMM, individual attorneys, or personnel, or the opinions of
MMM clients.
•
The materials and information are for the sole use of their
recipient and should not be distributed or repurposed without the
approval of the individual author(s) and Morris, Manning & Martin
LLP.
•
This document is Copyright ©2011 Morris, Manning & Martin,
LLP.
All Rights Reserved worldwide.