A Seven-Step Approach to a Clinically Integrated Network

A Seven-Step Approach to a
Clinically Integrated Network
April 28, 2016
Track B – ACOs, Population Health, Affiliation and Other
Issues

2 ©2016 Conifer Health Solutions, LLC. All Rights Reserved.
Presenters
Gayle L. Capozzalo, FACHE Executive Vice
President/Chief Strategy Officer,
Yale New Haven Health System
Megan North President, Value-Based Care,
Conifer Health Solutions

Learning Objectives
 Identify the elements associated with building a
clinically integrated network including the legal, clinical
and financial considerations impacting each party that
may ultimately participate in the new entity.
 Understand the criticality of accurate data to
benchmark the quality of care, utilization of resources and
cost efficiencies to develop a sustainable governance and
incentive structure for the clinically integrated network.

About Yale New Haven Health System
FY 2015
Critical Indicators System Total
Total Licensed Beds 2,130
NEMG Providers 750
Inpatient Discharges 111,563
Outpatient Encounters 1,857,501
Physician Visits >700,000
Net Revenue $3.6 B
Operating Income $159.7 M
Total Assets $4.4 B
Medical Staff 6,000
Employees 20,800
 Founded in 1995
 Corporate Members
» Yale-New Haven Hospital
» Bridgeport Hospital
» Greenwich Hospital
» Northeast Medical Group
 Clinical Affiliates
» Bristol Hospital
» Day Kimball Hospital
» Charlotte Hungerford Hospital
» Lawrence & Memorial Hospital
» The Westerly Hospital, RI
» Sharon Hospital
» Griffin Hospital
» Waterbury Hospital
» Eastern Connecticut Health Network
» Milford Hospital
» Middlesex Shoreline Medical Center
» Saint Francis Hospital
 Affiliated with the Yale School of Medicine

Yale New Haven Health System’s Vision & Values

About Conifer Health:
Performance Improvement Solutions to Better
Financial Performance and Clinical Outcomes

YNHHS: Moving from Volume to Value
Volume
• Revenue driven
• Limited incentives for
quality, safety or
coordination
• Minimal alignment/
integration across the
continuum; focus on
specific provider
• Focus sick care v.
well care
Value
• Cost driven
• Incentivized for optimal
quality, safety and
patient satisfaction
• High degree of
alignment across the
continuum; focus on
advancing the network
• Focus on well care and
population health
Elements of value
can improve
performance now
by maximizing
margins;
controlling costs;
and enhancing
quality, safety and
satisfaction
Maximizing value is
required, but
transitioning too
quickly may
compromise
current financial
performance

 Ensuring the financial health of clients on their
contracts
 Infrastructure to support an insurance license
 Actionable financial performance data
 Focusing on the right population
 Coordinating hand-offs
 Engaging individuals
 Actionable population data
 Aligning a network
 Integrating providers and data across the network
 Actionable clinical data
 Optimizing the full revenue cycle process, from
patient intake, through coding and documentation
to A/R management
 Build the foundation to evolve to Fee for Value
The Path to Value-Based Healthcare

• Improves access to quality care
• Manages health of populations
across state
• Manages patients across
continuum of care
• Achieves collaborative scale
• Drives common usage of:
• Data platform
• Metrics and measurement
• Evidence-based best
practices
Connection brings multiple benefits:
YNHHS: Benefits to Clinical Integration

At-A-Glance: Steps To Integration

Key Points:
• Decide if the network will be regional,
statewide or only encompass a few
counties
• Leverage admissions data to know your
top referrers and talk with them first.
• Itemize capital and resource
commitments and determine the
technology you will use early in the
process
Best Practices:
• Understand market drivers
• Leverage existing admissions data
• Host exploratory conversations
YNHHS Market Drivers
• Cost Rising > Inflation
• Connecticut Medical Reductions
• Consumerism
• Aging Population
• Constrained Resources
• Challenges to Value Proposition
YNHHS 60% Saint FrancisCare 40%
Step 1: Gather Interested Stakeholders

Key Points:
• Value propositions serve as building
blocks and lead to strong governance
• Every stakeholder will help define the
network’s value; physicians must lead
patient care processes
• Articulate how the network will better care
for patients, together
Best Practices:
• Physicians take the lead
• Focus on patient care and satisfaction
• Consider key audiences
Step 2: Create a Value Proposition

Key Points:
• Determine where decision-making
authority will reside
• An entity with single-signature
contracting capabilities enhances
leverage with payers
• Consider at least two layers of
participation agreements:
• local clinically integrated groups
• independent physicians
Best Practices:
• Give each network stakeholder a voice
• Define board responsibilities upfront:
• Budgets and capital investments
• Transactions on behalf of entity
• New membership acceptance or
termination
• Contract strategy and negotiation
• Determine strategy for existing networks
and long-standing partnerships
Step 3: Develop Governance and
Participation Agreements

YNHHS: Network Structure

Data Sources:
• Medical Claims (including CPT-II codes for
non-billable events)
• Pharmacy Claims
• Clinical Events from EMRs and labs
(biometrics, lab values, screenings, follow-ups,
immunizations)
• Survey data at an aggregate (down to
physician) level
• Measures chosen from:
• PQRS
• HEDIS
• IQR/OQR
• AHRQ
• MSSP ACO
Key Points:
• Begin by measuring quality not
clinical outcomes
• Identify measures then review
claims-based data to gauge
provider performance
• Quality data also pin points patient
education opportunities
Best Practices:
• Form a quality measures committee
• Review national standards
• Document quality measures
• Leverage technology to irack and
improve
Step 4: Select Quality Measures

Actionable Data Key to Achieving CIN Success

Step 5: Recruit Physicians
Key Points:
• Identify types of providers the network needs
• Review existing clinical performance metrics, if
available
• Personalize the reasons for joining the network
• Isolate provider gaps and overlaps in the care
network; understand that few networks are fully
formed right out of the gate
Physician Recruitment Flow Chart
Best Practices:
• Tag physician-executive champions
• Clearly define participation criteria
• Prioritize and assess providers
• Formulate a detailed recruitment strategy

Key Points:
• Primary care physicians are central
to managing patient care across
specialties
• Train all providers on quality
measurement and reporting
• Communicate regularly to drive
network’s support of better patient
outcomes
Best Practices:
• Educate providers and staff on
measurement tools
• Highlight the central role of primary
care
• Make patient education and
outreach a priority
Step 6: Measure and Improve Programs

Step 7: Engage Payers
Key Points:
• Understand risk and the costs for each
member per month
• Explore Medicaid Managed Home and
government contracts
• Consider adding your own employees to
the new CIN first
Best Practices:
• Develop population health management
capability with employees base
• Leverage benchmarks and experience
gained from other risk models (shared
savings, bundled payments, etc.)
• Use contract renewal periods to
introduce new CIN to payers

Conclusion: Connecting the Elements
Improve Access
Improve Health
Improve Value

Bibliography/References
 “Explaining Health Care Reform: Risk
Adjustment, Reinsurance, and Risk Corridors.”
Kaiser Family Foundation. 22 Jan 2014.
http://kff.org/health-reform/issue-brief/explaining-
health-care-reform-risk-adjustment-reinsurance-
and-risk-corridors/
 “US Health Sector Report 2015-16 - New
horizons: After reform: transformation.” EY
Healthcare. December, 2015.

A Seven-Step Approach to a Clinically Integrated Network

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