Through clinical integration, independent and hospital-employed providers can join together in an organization that allows them to: (1) identify and adopt clinical protocols for the treatment of particular disease states, (2) develop systems to monitor compliance with the adopted clinical protocols and (3) enter into provider-directed "pay-for-performance" and other contractual arrangements with health plans to financially recognize providers’ efforts to improve health care quality and efficiency. In summary, a clinically integrated network is a group of physicians organizing themselves to improve cost and quality by operating under a shared set of clinical guidelines and measures. Access a brief 2-minute video by The Advisory Board Company at https://www.youtube.com/watch?v=WVbMegDGtK4 to learn what it means to be clinically integrated.
Providers have multiple and overlapping motivations for joining together in a clinically integrated network, including: (1) to enhance the quality of the care provided to all patients, (2) to collectively build and obtain access to information technology and clinical resources necessary for population health and (3) to build a network of providers to market to payers and employers on the basis of quality and efficiency.
The objective of the clinically integrated network is to deliver high-value care which meets the Triple Aim for all children, specifically better care, smarter spending and healthier children. CMHN believes value-based payment contracts and clinical integration between community and health system providers are necessary to align incentives and create an integrated and coordinated care management approach.
Healthcare delivery in the United States is in the midst of a transformation as the payment model shifts from a fee-for-service to fee-for-value model. This shift necessitates an integrated approach to care management that is scalable and distributed in a geographic presence. CMHN's clinically integrated network allows providers across the continuum to achieve these goals and position themselves for success in a new era of healthcare delivery. Additional benefits of CMHN membership include:
Partnering with CMHN provides distinct advantages to independent providers, including: (1) providing administrative, clinical and analytical expertise and resources, (2) leveraging necessary technology infrastructure and expertise, (3) broadening the scale and scope of services that providers can provide to patients, and (4) demonstrating the value of clinical integration to payers and the community.
Providers and hospitals nationwide are implementing clinical integration programs because of the value proposition:
Clinical integration allows providers to: (a) demonstrate their quality to current and future patients, (b) participate in establishing the clinical measures against which they will be evaluated, and reduce their exposure to arbitrary measures imposed by health plans that are often not applicable to pediatrics, (c) enhance revenue through patient outreach and better management of chronic, high risk and/or high cost patients, and (d) collectively build the necessary population health infrastructure.
Clinical integration gives hospitals the ability to: (a) demonstrate their quality to current and future patients, (b) enlist provider support for quality and efficiency initiatives, (c) develop a better, more collaborative relationship with independent providers, (d) shift toward and improve performance on pay-for-performance and value-based agreements and (e) position themselves as quality leaders in their service areas.
Clinical integration provides patients with: (a) better value for their health care dollars, (b) more effective case management, care coordination and outreach from a trusted source; their provider and practice support staff and (c) more reliable information to support their choice of providers, hospitals and other clinical services.
Clinical integration gives employers: (a) the ability to more effectively manage the health care costs of employees and their dependents through the purchase of more efficient health care services, (b) increased employee productivity and reduced absenteeism, through better management of chronic diseases and high risk patients and (c) more reliable information to support conversion to consumer-driven health insurance products.
To enable the network to deliver high-value care, provider members of CMHN's clinically integrated network function as partners in the management of CMHN's clinical integration program. Through CMHN's operating board and committees, the providers in the clinically integrated network are responsible for determining the clinical guidelines, quality measures, methods of practice, and performance requirements.
CMHN is led by an Operating Board and committee structure comprised of the network providers and supported by professional management services. The Operating Board is responsible for the development and implementation of the CMHN goals and objectives and is ultimately responsible for the approval of work completed by the CMHN Committees. The majority of the Operating Board consists of representatives of independent network physicians.
The Clinical Quality and Clinical Practice Standards Committee has a physician representative from each practice and a chair elected by the committee members. The chair of this committee is also a member of the Operating Board. This committee reviews and selects clinical focus areas for target improvement and develops clinical practice standards applicable to the network of providers. In addition, the committee has established standards for measurement and monitoring of performance that support the goals of the network. These standards are submitted to the Operating Board and are continually monitored.
The Network Business Operations Committee also has a member representative from each practice. This person may or may not be a physician and can be a practice manager or another representative from your practice. The elected chair of this committee is a member of the Operating Board. This committee is responsible for the development of network operating guidelines and policies including participation requirements and payer contracts. These standards are submitted to the Operating Board and are continually monitored.
CMHN requires the active participation of the entire network, which is key to the success of the program. The structure and functions of the Operating Board and the Committees is set out in a Charter.
The clinical focus of CMHN is determined by the network’s providers via the Operating Board and committee structure, which as noted above has strong representation by providers. Often, clinically integrated networks seek to improve chronic disease management, care coordination, transitions of care, community/practice-based case management and communication among primary care providers and specialists.
Yes, although the degree to which change is required will vary based on the degree to which providers have already implemented the components of the CMHN. Participation in the quality and care management initiatives of CMHN will require significant time and attention from the providers and their office staff. Providers must adhere to agreed-upon guidelines and performance measures with the goal of improving quality and reducing cost. CMHN will pursue new value-based payment models that may allow CMHN providers to share in savings when the value of care improves.
An Electronic Medical Record (EMR) is important technology necessary to support the network's health care quality initiatives, improve care coordination, facilitate clinical information exchange and strive toward the objective of delivering high-value and integrated care. EMRs also provide reliable access to complete patient information and real-time clinical decision support. Furthermore, EMRs are essential tools to support the PCMH care model and are necessary to deliver better experiences and better outcomes for patients.
All CMHN practices are required to have an EMR or have a specific plan to acquire and implement an EMR in the future.
A practice does not have to have NCQA recognition to join the CMHN. Importantly, the Medical Home Model encompasses much more than the NCQA recognition alone. The Agency for Healthcare Research and Quality (AHRQ) defines a medical home "not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care." The CMHN Development Plan states that a Provider must be "recognized by the NCQA, or such other accrediting body as may be designated by the Operating Board, as a Patient Centered Medical Home (""), or participate in CMICS’s PCMH development program for the CMHN."
As outlined above in the definition and objectives of clinical integration, becoming clinically integrated requires controlling costs and improving the quality of health care services for all patients. Clinical integration requires data for all patients and across all payers.
Members of CMHN are required to share clinical and billing data sourced from your practice management system and/or EMR. The data collection process is facilitated by CMHN using an efficient, secure and automated technology. The data initially required from community practices includes information typically entered on a HCFA-1500 form, including patient demographic information, provider information and diagnosis and procedure codes. Actual charge and payment information is not included.
After a practice terminates with Children’s Mercy Health Network, Valence Health will contact and work with the practice to uninstall Valence Health’s data feed technology. No data will be collected or loaded into the Valence solution for services rendered after the practice’s termination date. Data associated with services rendered prior to the date of termination must be retained for CMHN's clinical integration program to support ongoing maintenance of the network’s quality measures.
No. The Children’s Mercy Health Network’s clinical integration program is a non-exclusive organization, making no limitations on a provider’s ability to admit patients to non-Children’s Mercy sites of care or a provider’s ability to maintain contracts with health plans on an individual basis.
Each CMHN physician pays an annual per physician fee that is used to maintain the professionally managed infrastructure necessary to achieve CMHN goals and objectives. The 2020 annual fee is currently set at $390.00 per physician. The annual fee is based on a fair market evaluation completed by an independent valuation expert. The membership fee will be reviewed annually or as needed. Any other assessments will be approved by the Operating Board.
PCN’s innovative care and payment delivery model has aligned incentives for providers serving patients enrolled in Medicaid and the Children’s Health Insurance Plan (CHIP). CMHN expands the PCN concept to all patients. Medicaid/CHIP agreements continue to be managed by PCN; CMHN focuses exclusively on commercially-insured and employer-based populations.
Physician leadership, provider participation and professional management are keys to the success of CMHN. Physicians from those practices who join during the formation of CMHN participate in the development of a common set of clinical practice guidelines, quality goals and performance measures that will be the basis of CMHN commercial contracts. Participation in this process is essential to the development of CMHN's clinical and operation processes and goals. If the practice joins CMHN 90 days prior to the effective date of a payer contract(s), the practice’s participation in the payer contract(s) will be consistent with the effective date of the payer contract(s). If the practice joins CMHN after 90 days prior to the effective date of a payer contract(s), the practice will be eligible to participate with that payer contract(s) on the first anniversary of the payer contract(s) after a minimum of six months waiting period.
No. Providers who join CMHN will only be asked to delegate their contracting for agreements entered into by the network. Membership in CMHN is non-exclusive, meaning members are not prohibited from pursuing other payer contracting arrangements either independently or via another organization. The intent is for CMHN to focus on value-based agreements with payers and employers.
Providers who join CMHN are asked to delegate their contracting for agreements initiated by the network; existing practice agreements are not impacted. Initial CMHN contracts are intended to supplement and enhance your existing contracts. In other words, the practice would retain existing contracts with the specific payer and the CMHN agreement would "wrap around" that agreement with additional compensation opportunities.
CMHN is a non-exclusive arrangement. This means members are not prohibited from pursuing other payer contracting arrangements either independently or through another organization. However, members must participate in all contractual agreements entered into on behalf of CMHN (and approved by the CMHN Business Operations Committee). Your practice will always have the opportunity to evaluate these agreements, and if you do not wish to participate, you may withdraw your membership in the network. CMHN members can cancel their CMHN contract at any time without cause by giving at least ninety (90) days prior written notice. Cancelling your CMHN contract will end your participation with any and all CMHN payer agreements, population health management tools and patient centered medical home assistance.