February 5, 2019 · 2019. 2. 5. · Evaluate business case and motivation for collaboration around...

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Community HealthCare Association of the Dakotas:

Introduction to Clinically Integrated Network Exploration

February 5, 2019


… Who We Are

Starling Advisors works nationally with Health Centers, Networks, and PCAs to answer the question:

“What changes, if any, do we need to make to insure a role in providing high-quality, comprehensive primary care under

Health Reform?”

www.starlingadvisors.com 2


Your Starling Advisors team

Andrew Principe

[email protected]

Amanda Stangis

[email protected]

Samantha Jones

[email protected]

3www.starlingadvisors.com

mailto:[email protected]




Why are we here?

• The Board of the Community HealthCare Association of the Dakotas directed the Association to explore the potential for establishing a “Clinically Integrated Network.”

• This webinar marks the formal beginning of that exploration.

• In today’s discussion, we will:• Define Clinically Integrated Networks and discuss the process of Clinical Integration• Provide an overview of our Process for Exploration• Discuss what happens after the Exploration Process is complete• Give you immediate next steps to take to participate in the process• Address any questions or concerns you may have



WHAT IS CLINICAL INTEGRATION?

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Core Guiding Principle

To remain competitive with non-Health Center based primary care, we believe most Health Centers will

participate in Clinically Integrated Networks.

• Some of these networks will be hospital-centric.• In other cases, these networks will be formed and managed by Health

Centers.• In many states, Health Centers have already begun forming and operating

Clinically Integrated Networks.

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What is a Clinically Integrated Network

A Clinically Integrated Network is a group of independently owned and operated healthcare provider organizations that work together to improve patient outcomes, reduce total cost of care, and improve patient experience…

By integrating, the Network:

• May participate in joint contracting for value-based incentives or base-payments

• Receives protection from anti-trust claims at the Federal and State level

As a result, many groups of Health Centers see Clinically Integrated Networks as an ideal way to participate in Value-Based Payment models.

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What are Value-Based Payments?

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What can networks offer?

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The ”Network” should assist its participant organizations in improving quality, reducing total cost of care, managing high risk populations of patients, and increasing the collective scale and leverage in negotiations.


Why is Clinical Integration important for networks, payers and providers?

• Seek scale that is consistent, repeatable, and broad• Expect effective and efficient clinical and financial outcomes Payers

• Benefit from having their care managed across care settings• Seek consistent, reliable, and trusted interactions with their providersPatients

• Benefit with more comprehensive information about individual patients across care settings

• Advantaged when health planning can occur across a population of patients

Providers

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Information Technology

Performance Improvement

Participation Criteria

Legal Entities

Joint Contracting

Flow of Funds

Clinicians Leadership

ACCOUNTABILITY

What does it take to achieve Clinical Integration?

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What does it take to achieve Clinical Integration?

Requirement Detail

Participation Criteria • A network must be selective in choosing its participants based on a set of standards. These standards should help ensure the network is likely to achieve its goals.

Performance Improvement

• A network should maintain and execute a network-level plan for improvement performance in quality, cost, and patient experience.

Information Technology

• Virtually all networks achieve their goals with some form of shared Information Technology. This may involve shared EHR but it is not required.

Joint Contracting • Networks enter into contracts as a single entity, therefore, its participants are either successful together or they fail to achieve incentives together.

Physician Leadership • The network must show that its strategies are developed in the best interest of the medical needs of the patients, and clinician leadership is the best way to demonstrate that.

Flow of Funds • The network must demonstrate that it has made sufficient investment in its operations, and must show that gains are paid to participants to incentivize their enhanced performance.

Legal Entities • The network should be a distinct entity from its participants for a variety of legal reasons.



NETWORK EXPLORATION PROCESS


Exploring a Clinically Integrated NetworkProject Goals

Evaluate business case and motivation for collaboration around value-based contracting – payer mix, market scan

Prioritize needs to achieve Clinical Integration – legal requirements, operational components

Engage health plans in discussion around value-based reimbursement – validate business case



Goals of the Network Exploration ProcessBusiness Case and Motivation

• Determine if there is a business case for CHAD Members to collaborate on the development of new network• A business case suggests that the Network is likely to achieve financial sustainability and

contributed financially to its participant Health Centers• The business case is derived from the value-based payments paid to the network and then to the

Health Centers• The business case may also include cost savings or economies of scale that are created by

pooling resources and capacity across a group of Health Centers

• Determine if there is willingness and motivation to work together to develop a new network • Even with a great business case, the Network will fail if its participants do not wish to work

together • Working together means agreeing to do some things consistently across organizations and/or

participate in shared services provided by the Network

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Goals of the Network Exploration ProcessLegal and Operational Requirements

• The Network must overcome some legal requirements prior to negotiating on behalf of its participants• A new entity will likely be formed, with its own operating agreement (similar to by-laws) and

governance structure (board and committees)• Certain policies and procedures will be adopted and codified through a participation agreement

• In addition the Network will develop an operating model that will address other elements of clinical integration • The Network will work to standardize how Information Technology is used by its participants,

establish performance improvement programs, contract on behalf of its participants, and take in and distribute incentive payments

• While much of the clinical programming can be done at the participating Health Center, the network must prove that the Clinical Integration would not exist without the network

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Goals of the Network Exploration ProcessEngaging Payers

• Ultimately, the sustainability plan for the Network depends on its ability to engage with Payers on new types of contracts

• Although existing Health Center payment models will remain intact, the Network will attempt to create payment options above current base compensation.

• As a part of the Exploration, it makes sense to have introductory conversations with Payers:• The goal is to assess their interest in future value-based payment contracts

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Member Survey

1. Distributed via Survey Monkey.2. Areas of exploration:

1. Health Center basic demographics2. Network capacity3. HIT and Care Coordination capacity4. Payer information – Medicare,

Medicaid, Commercial5. High priority service lines

3. Surveys will be sent by 2/6/19 and will be due by 3/1/19.

Key Informant Interviews

1. We will facilitate 5 interviews with “key informants” which could include FQHC leaders/staff, Health Plan leaders and/or Other healthcare stakeholders or leaders at the request of CHAD and its members.

2. These interviews will be used to inform the Business Model and Pro Forma.

3. We will conduct these interviews February-March.


Data GatheringMember Survey & Key Informant Interviews


Survey Guidance – Patients and Encounters

• You will be asked to provide basic information about your practice.

• For unique patients and total encounters, you can use the same methodology as your UDS report



Survey Guidance – Patients and Encounters

• Later in the survey, you will be asked to split the same information out by Payer.

• We are attempting to understand the total scale of the network as it relates to each payer. If you have questions, please contact us before completing the survey.



Member EducationWebinar Series

• There will be two additional webinars to learn more about Clinical Integration:• March 5th, 2019 11AM Central: Legal and Operational Requirements of Clinically

Integrated Networks – maximizing our leverage and improve population health while staying compliant with legal and regulatory requirements.

• April 2, 2019 11AM Central: Governance and Equity – understanding how your Health Center will participate in, and benefit from, Clinically Integrated Network activities.



Business Model, Pro Forma, and Roadmap DesignPutting a Plan Together

• Starling will facilitate a network design that includes three deliverables:• A Business Model – what services will the network provide to meet the requirements of

Clinical Integration and best position the members to maximize their gains under value-based payments.

• A Pro Forma – what will it cost to build and run a network, and how will it become self-sustaining.

• A Roadmap – the steps and timelines to that describe how do we get there, from here?

• CHAD and CHAD Members will have input into the development of these deliverables, which will culminate in the onsite meeting in May.

• We will be developing draft materials in March and April, and finalizing after the May onsite.



May OnsiteReviewing Progress and Making Decisions

• In May, a comprehensive strategy session will be facilitated by Starling for all CHAD members.

• The goals are to review a comprehensive draft of the Business Model, Pro Forma, and Roadmap.• We will solicit input.• We will frame key decision points.• We will work to secure interim (non-binding) buy in and commitment.



Finalizing the ApproachMoving towards Formal Action

• Following the onsite final versions of the Business Model, Pro Forma, and Roadmap will be prepared to facilitate the appropriate formal action of the CHAD Board as well as individual members.

• Your organization will reach its first toll-gate: a point at which a decision will be made to continue on or to exit from the process.



WHAT HAPPENS IF YOU MOVE FORWARD?


Success Predictors

1. Early role clarification - Establish the role of each party- Health center participation in strategy and development - Defining the relationships with existing networks

2. Aligning priorities and expectations

3. Shared understanding of the network models and their constructs and opportunities

4. Identifying an effective governance model

5. Establishing agreement on participation standards

6. Availability of data

7. All partners financially invest in the process

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5 Biggest Mistakes of Those Who Wish to Build Networks

1. Way too much focus on contracting / not enough focus on value.

2. Building too large of a Board.

3. Poorly communicating with the Health Center Boards until too late in the process.

4. Not taking advantage of legal structures designed for this type of activity.

5. Underestimating the work involved.

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And the next 1000…

Losing momentum…

Inability to share data…

Unwillingness to compromise on clinical guidelines…

Underfunding…

Defensiveness around areas we see ourselves as successful…

Getting into anti-trust trouble…

Overestimating our scale…

Not taking advantage of programs that can help us…

Assuming this can be done FOR you and not BY you…

And on…

And on…

And on…

Focusing on how to share proceeds at the expense of how to generate them…

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Year 1: Sample Integration RoadmapCore

Strategy Activities

(Examples)Deliverables(Examples)

Identify Clinical Performance Standards

• Standards based on 2016 contract requirements and other reporting obligations

• Establish performance management processes• Identify Evidence Based Guidelines based on Y1 Standards

• Gain sharing policy• Participation agreement amendments• Quality Improvement /remediation plan for under

performers • Documented performance baselines and Y1 progress

Planning for Technology and Data

• Data collection and analysis Y1 strategy • Analysis of patient/provider portals/IT• Preliminary planning for claims data • Preliminary planning for UM• Comprehensive plan for 2017 for centralized data analytics

strategy

• Data reports• Claims management work plan with MSO partner for Y2• UM work plan with MSO for Y2• Data analytics

Establish Shared Clinical Programs

• Establish a network-level QI plan• Shared patient engagement/ satisfaction programs• Implement a network-level care management program

• QI plan documented• Patient engagement and patient satisfaction tools

documented• Care planning protocols developed, templates created,

care coordination infrastructure implemented

Leverage Clinical Integration withPayers

• Legal opinion on clinical integration• Utilize demonstrated effectiveness and efficiency in contract

negotiations for 2018

• Payer contracts

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Operationalize the Business Planning for the New Network(Approximately 6-12 months)

MOU to commit to

work together

Make key strategic

decisions about governance and

ownership

Sign operating agreement and begin operating formally

Ratify clinical integration

strategy

Close gaps in operating

infrastructure to support

integration

Seek legal opinion on anti-trust protection

Contract

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IMMEDIATE NEXT STEPS


Next Steps

• You will each receive a SurveyMonkey link to complete the survey.

• Please plan to have someone from your Health Center attend each webinar. We recommend at least one C-level attendee at each webinar, and you may include anyone else you like.

• Between now and May, CHAD and Starling, with considerable member input, will develop a model for a Clinically Integrated Network including a Business Model, Pro Forma, and Roadmap to Success.

• Plan to be onsite with us in May for the face-to-face planning session.



Questions?


February 5, 2019 · 2019. 2. 5. · Evaluate business case and motivation for collaboration around...

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