New Risk and Collaboration Models
for Providers
Clinically Integrated Network
January 2014
Agenda
Objectives for Today
 Provide a brief history and context
 Share the vision, objectives, and strategies
 Review the model of care
 Review Physician Care Network’s clinical and administrative services
 Provide a status of recent activities and upcoming milestones
 Share the requirements and benefits of physicians joining the CIN
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Background
Market & Competitive Pressures
Hospitals
 Consolidating; increasing negotiation strength
 Employing primary care and specialty physicians
Health Plans
 Creating narrow networks and increasing price pressure
 Implementing bundled episodic payments
 Pushing risk based payment and shared savings models
 Tying quality metrics to reimbursement levels
 Requiring changes to protocols and treatment to improve outcomes
 Demanding significant data compilation required to track and monitor
Result: A serious threat to the long-term viability of physician owned practices
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Addressing the Threat
Plan of Action
 In 2013, the Northwest Medical Group Alliance initiated a study to determine the
feasibility of creating a physician-led, Clinically Integrated Network (CIN)
 Their network of over a dozen independent physician practices with more than 700
physicians is sufficient for limited network products
 The proposed CIN delivery model is marketable and the timing is optimal
 Hospital affiliation is not a priority
 Member participation criteria can be met by most, if not all, medical groups in the
Alliance and beyond
 The right vehicle for the CIN is the Physicians Care Network (PCN)
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Physicians Care Network
Overview
 Formed in 1997, serves as a mechanism for sharing financial risk through clinical
integration across multiple medical group practices
 Contracts with various health plans on behalf of its Members and administers quality
and care management programs in accordance with payer terms and conditions
 Integration across care settings of standardized clinical protocols
‒ Steerage of patient care to lower cost settings
‒ Utilization management of high risk populations
‒ Formularies that promote generic drug use
 Develops the provider network for health plans
‒ Billing, credentialing, administration of risk pools and other risk sharing arrangements
‒ Management information services related to administration of those contracts
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Physicians Care Network
Overview (continued)
 Engaged with four Medicare Advantage (MA) health plans
‒ PCN participates with three of the four MA health plans under full risk, fully delegated (care
management, claims, credentialing) arrangements
‒ Participates in the Medicare ACO Shared Savings Program with the Centers for Medicare and
Medicaid Services (CMS)
‒ Contracts with four health plans that focus on shared savings and reduction in the total cost of
care delivered to plan beneficiaries
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Vision & Business Aims
Vision
Enable independent physician practices in the Pacific Northwest to
remain independent and thrive in the new healthcare environment
Business Aim
Develop and operate a clinically integrated network of independent physician practices
that secures and supports performance of value-based contracts that reward practices
for delivering high quality patient care in an efficient manner
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Strategies
Achieving the Business Aim
 Create a robust and engaged clinically integrated network of independent physician practices
 Identify, secure, and deploy an essential infrastructure to support CIN operations in a costeffective manner
 Engage physicians as leaders and full participants in the CIN's development and operations
 Support participants’ practice transformation efforts
 Identify, evaluate, and pursue network value-based payor contracting opportunities
 Develop the capacity to accurately report the health status of defined patient population(s)
 Ensure participants’ adherence to CIN-approved evidenced-based standards of care
 Deliver "high-touch" care coordination for high-risk and patients who may become high risk
 Deploy proven patient engagement tools to manage network patients
 Develop metrics and measure outcomes for continuous quality improvement
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Desired Outcomes
Outcomes
 Engage a critical mass of independent physician practices as CIN participants
 Create a sustainable business model to support essential CIN infrastructure and
services to its participating practices
 Transform participants’ practices to engage in population health management
 Secure favorable value-based payor contracts for CIN participants
 Demonstrate quality through participants’ achievement of specified standards
 Reduce the total cost of care for defined population(s) by specified targeted amounts
(percentage reductions)
 Improve the overall patient experience of care
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Model of Care
Scalable Services to Meet Patient Needs
High risk – high cost,
complex needs
Cost Containment, support and
coordination
Rising risk – at least
one chronic condition
Motivational Interviewing,
closing care gaps, strengthening
relationship to PCP
Low risk
Engage, set the stage
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Model of Care
Enhanced Care Model
 Care coordination service delivery model with a focus on keeping patients healthy over
time through screening and prevention, early intervention, health education, and
meaningful management of chronic conditions
 High risk / high cost patients actively managed and transitioned from high cost hospital
based services to lower cost community based and home based care
 Primary care providers rewarded based on the outcomes they achieve rather than by
the number of exams they provide or tests they order
 Evidence based clinical protocols, vetted by extensive research, and determined by
experts to be most effective compared to other treatment options
 Information sharing occurs across care settings to reduce duplication of unnecessary
diagnostic and treatment orders and eliminate waste
 Formularies that include step-therapy and increased use of generic drugs
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PCN Services
Care Management Services
 Train and coach providers on the Enhanced Care Model
 Establish and disseminate CIN guidelines and protocols (in collaboration with Member
groups)
 Promote practice improvement, quality, and cost management goals
 Collaborate with Member groups to establish quality and cost measures and clinical
benchmarks that drive health system change
 Extend risk identification and care management tools and processes to Members
 Provide risk adjusted coding training and services
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PCN Services
Administrative Services
 Create the CIN, secure investors, and implement
 Prepare legal documents for the joint venture: Bylaws, Articles of Incorporation, etc.
 Develop Member participation agreements and negotiate contracts
 Engage health plans and negotiate innovative payment models
 Administer payment models
 Develop prospective budgets and resource planning
 Develop initial performance measures and baseline statistics
 Brand, manage, and expand the network across the state
 Manage CIN staff and liaison with in-kind services provided by Member groups
 Credential Member physicians
 Provide decision support and analytics tools and processes
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PCN Systems
Primary Systems
Phytel/Verisk – Concurrent and retrospective review
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Stratify, validate, and manage risk
Identify care gaps
Assist with quality indicators; track and trend quality measures
Track population health around complex and chronic conditions
Aggregate disparate data sources into consistent data sets for analysis and comparison of quality
and cost metrics
 Assist staff in its patient outreach activities through a set of protocols that support preventive and
chronic care follow-up
EZ-Cap – Administration
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Referral and Authorization Management
Customer Service
Encounter Submissions
Reporting
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CIN Status
Recent Developments
 Negotiated a term sheet with investors and gained agreement to move forward and
engage provider groups
 Developed milestones to ensure progress, safeguard ongoing capital investment, and
provide investors with some assurance for their investments
 Updated the Participation Agreement and created supporting materials for engaging
prospective provider groups
 Prioritized the list of potential provider groups
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CIN Governance Model
Clinically Integrated Network
Board of Managers
Executive Director
Medical Director
(also supports MA business)
Population Health
Management
Performance
Improvement
Physician lead/controlled committees
Contracts
Technology
Business lead/controlled committees with physician participation
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Revenue Model
Care management fee (e.g.PMPM)
This approach…
 Ensures there is immediate revenue to help offset operating costs
 Provides an alternative to health plan contracts that only provide the potential for
limited savings at the end of a contract period
 Avoids the diminishing returns associated with continuously squeezing costs out of the
system
The CIN plans to charge a flat per member per month (PMPM) fee
 A flat fee across the entire population is much simpler than charging a much higher fee
for only the high-risk patients; it also provides a more predictable revenue stream
 This approach is not unique; it is consistent with other PCN and standard industry
arrangements
 The up-front fee may have to work in conjunction with a shared savings arrangement
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Next Steps
Upcoming Activities
 Formally create the CIN enterprise
‒ Execute the Term Sheet
‒ Form the CIN legal entity (Operating Agreement, Articles of Incorporation, Bylaws, etc.)
‒ Elect the Board of Directors; form and charge committees
 Immediately kick off the next phase of provider group engagement
 Execute contracts with health plan(s)
 Complete the recruiting process and hire a Medical Director as soon as possible
 Engage a CIN consulting firm to support implementation
 Create a formal budget for 2015
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Important Dates
2015 Milestones
1/1/2015
Form and
Capitalize Entity
2/1/2015
Operationalize
Committees
4/30/2015
Health Plans
File 2016 Products
9/1/2015
Population Health Systems
Available to Members
1/1/2015
1/1/2016
Members Enroll in
New Product(s)
1/1/2016
3/31/2015
Health Care Authority
Selects 2016 ACO Partners
4/1/2015 - 9/30/2015
Implement
Model of Care
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Joining the CIN
Membership Participation Criteria
 Use a certified electronic medical record system
 Meet or be in the process of meeting Meaningful Use standards
 Identify and track at least one patient population or chronic condition
 Have experience tracking some patient costs
 Have process in place for managing transitions of care
 Use ePrescribing, CPOE or electronic results reporting
 Agree to cost management and performance risk management protocols
 Agree to share data transparently
 Agree to adopt the new model of care
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Joining the CIN
Member Benefits
 The ability to remain independent as an alternative to large health system employment
‒ With a number of quality focused provider groups, anchored by The Polyclinic and supported
by Physicians Care Network, the CIN will enable independent physicians to participate in riskbased, total cost of care contracts that they would otherwise not have access to
‒ This is critical to practice survival as health plan products are increasingly steering patients to
narrow networks
 Enhanced provider leadership over clinical decisions through selection and
implementation of evidence based clinical protocols
 Decision making seats on committees and influence to Board decisions
 Innovative care delivery alternatives that enhance patient experience that, in turn,
leads to growth in market share and revenue sharing opportunities
 Access to population health management tools
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Joining the CIN
Member Benefits (continued)
 Training and administrative services that streamlines data compilation and extraction
for health plan quality metrics management
 Financial analysis capabilities
 An environment where independent providers can support one another through
referrals, team based care, and care coordination while reducing the total cost of care
 Risk adjusted coding training and resources
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