ACO. MACRA. CJR. CIN. These are just some of the acronyms now common in the vernacular of hospital and health system executives nationwide.
Ushered in by an era of healthcare reform, these terms have many similarities with regard to their structures, and not just linguistically. For one, they’re all built on the concept of clinical integration—collaboration among physicians, hospitals and post-acute care providers to improve value across the continuum of care.
Think of clinical integration like your car’s chassis: a framework bringing together the different functions and stakeholders that allow providers to travel from volume to value. Forces like the Medicare Access and CHIP Reauthorization Act (MACRA) are accelerating the adoption of alternative payment models (APMs), including shared savings, Medicare’s Comprehensive Care for Joint Replacement (CJR) bundled payment initiative and other episodic payments. They are all built on this chassis.
But here’s the rub: Some providers approach clinical integration as a noun, a thing. They simply develop or join an accountable care organization (ACO) or clinically integrated network (CIN), and they’ve reached their destination. In reality, these value-based initiatives will remain in park unless providers consider clinical integration a verb, focusing on actions that drive the transition to value. They include:
- Creating durable relationships with health systems, physicians and other providers focused on common objectives, including clearly defined goals and incentive;
- Executing transformational clinical redesign to change how care is delivered across the continuum;
- Adopting contracts that support and monetize clinical program work, creating a vehicle for sustainable growth through differentiation;
- Leveraging IT and business intelligence to hardwire and monitor redesign in analytics, workflows and electronic health records; and
- Developing a strong physician leadership culture to support physician performance and team-based care, built on actionable data that delivers meaningful reporting.
Clinical integration in motion
Providers nationwide are developing clinical integration infrastructures built on action, and they’re seeing strong results.
St. Augustine, Florida-based Flagler Hospital partnered with more than 80 local physician practices to form First Coast Health Alliance (FCHA), the area’s first jointly owned physician-hospital organization.
Through the partnership, the CIN formed work groups leveraging data to identify and prioritize performance improvement targets, and develop protocols for addressing them. The data-driven approach was combined with a transparent physician compensation model developed by FCHA’s Finance Committee, which engages physicians in the success of the program.
The result: a 65% decrease in excess length-of-stay and a $3 million decrease in associated costs. FCHA also was selected to participate in the Medicare Shared Savings Program to share in cost savings they achieve for Medicare beneficiaries.
In the Twin Cities of Minneapolis and St. Paul, Minnesota, three independent health systems—Fairview Health Services, HealthEast and North Memorial Hospital—were grappling with a similar set of challenges, including an inability to sufficiently provide coverage to meet consumer access needs and escalating costs required to build a population health infrastructure.
In response to these barriers, the systems created a shared clinical integration structure, with clinicians from each network—including independent and employed physicians—collaborating around three focus areas: readmissions, emergency department utilization and women's health. The partnership allowed the systems to offer the state’s largest ACO to payers, resulting in PreferredHealth, a new group employer health plan providing access to more than 5,000 providers, 625 primary and specialty clinics and 13 hospitals. Since its launch in 2013, PreferredHealth successes include:
- An 11% lower risk-adjusted total cost of care index compared to a large open access network;
- A 10-15% differential in premiums paid by employers and employees;
- A superior quality index factor for five high-cost conditions (cardiology, endocrinology, gastroenterology, orthopedics and mental health/substance abuse); and
- A 470% increase in covered lives—from 7,000 to 40,000 members.
Newton’s laws of motion suggest an object at rest stays at rest, and an object in motion stays in motion. For providers, participation in an APM is an important step in the drive to value, but it isn’t the final stop on the journey. Clinical integration can accelerate the quantity to quality transition, but only if it’s focused on ongoing action and collaboration across all care sites and providers that promotes forward momentum.
Dennis Butts Jr. is a director with Navigant's Strategic Healthcare Transformation team, and has 14 years of healthcare industry experience. Dennis has led numerous healthcare strategic planning engagements, and is a nationally recognized expert in the design, development and implementation of clinical integration networks for single hospitals, health systems and academic medical centers.