As clinical integration (CI) networks mature, how do they move beyond basic performance improvement activities to meet broader goals for care transformation? The Health Care Advisory Board is beginning a new research initiative to examine this issue, studying how CI programs continue to evolve after they’ve established initial infrastructure and activities.
Read on to learn more about our (very preliminary) findings and offer your thoughts on what additional questions we could explore to make this research most useful to you.
Moving beyond the baseline
With industry interest in CI rising rapidly across the last few years, many hospitals and physician groups have been focused primarily on network establishment, with questions centered on the start-up phase: What does “clinical integration” mean? Should we pursue this strategy? How do we get our physicians and payers on board? How do we select initial performance metrics, build physician governance structures, and begin to deploy information technology?
For those who have not yet read it, our 2010 publication, Building the Performance-Focused Physician Network: Road Map for Assessing and Implementing a Clinical Integration Strategy, addresses these program development questions and more.
More recently, however, the tenor of the conversation has started to change. As more CI programs come online, and as more health systems recognize the potential to use those networks as a launching pad for “accountable care”—whether you use that term in the official Medicare sense or to more generally define an organization capable of managing population risk—the questions are shifting from “what is CI and how do we get it established?” to “how do we use this network we’ve built to drive delivery system transformation and significantly improve patient outcomes?”
This question is fueling a new Health Care Advisory Board research initiative examining next-generation CI programs. Through conversations with mature CI networks (loosely defined as those programs that have experience working with physicians on jointly negotiated, performance-based contracts who can point to some baseline returns from the strategy), we are hoping to better understand how programs are evolving as they mature past early developmental milestones.
While we’ve conducted just a few research interviews to date, we are hearing some striking similarities in the strategies pursued by these advanced CI programs. With the caveat that these findings are still preliminary, below are a few of the takeaways so far.
Preliminary Research Findings
Shared physician culture emerging—with time and effort
Several mature CI programs have successfully developed a shared culture of engagement across independent and employed physicians, but the shift did not happen overnight. Networks have spent years actively working to build engagement and buy-in among physician participants through constant communication, performance data transparency, financial incentives, and other strategies—work that is only just now beginning to show meaningful results.
Relationships tightening with hospital partners
Leaders of mature CI networks report playing a growing role in setting health system strategy, often helping to shift the organization toward a more “ambulatory-centric” identity, or one focused on improving care beyond the inpatient space in anticipation of increased population management risk.
On a more day-to-day level, hospitals are increasingly looking to the CI program—rather than other vehicles for medical staff engagement—to take the lead on inpatient quality and cost improvement. How this tighter relationship impacts governance structures, medical staff leadership, and other aspects of the traditional hospital-physician relationship is something we are still exploring.
Payer strategy evolving toward risk
Historically, CI programs have often asked payers to support their activities through higher fee schedules or quality-based bonuses. Now, mature CI programs seem to be moving instead toward payment structures that place the network at greater financial risk for outcomes, such as shared-savings contracts.
CI leaders note that risk-based contracts may be more palatable to payers, as the network gets paid a bonus only if it actually reduces costs rather than on the assumption that it will. Others see risk contracts as more motivational to physicians as well, clearly linking performance improvement to financial return. Some networks also report greater success at getting payers on board by asking them to fund specific aspects of program infrastructure (e.g., care coordinator salaries) rather than to pay extra money directly to physicians.
Increased interest in narrowing the physician network
While early-stage CI programs often cast a wide net in building program membership, some mature CI networks are starting to tier or narrow their provider networks more aggressively on the basis of performance or cultural “fit.” In some cases, this tiering is driven by the desire to funnel scarce infrastructure resources preferentially to physicians who are most likely to benefit from that support.
In other cases, it’s driven by a desire to “right-size” as the network takes on risk contracts, building a preferred provider tier no larger than what is needed to manage the program’s projected patient population. Again, how this tiering plays out in practice and what legal ramifications (if any) it might have are questions we continue to explore.
Focus shifting beyond metric setting to care standardization
For a new CI program, it can be difficult enough just to get physician buy-in for performance measurement, let alone for care pathways. But as CI programs develop stronger physician engagement, clinical standardization seems to become easier.
Indeed, the challenge becomes less about winning physician buy-in and more about how the program can accelerate the standardization process across hundreds of conditions or diagnoses, many of which cut across specialty areas and care settings. For several mature CI programs, creating structures and processes to meet this challenge represents a major current initiative.
Care management infrastructure continuing to grow
As networks prepare to assume more risk for population outcomes, they continue to invest in resources that support physicians in better managing chronic disease and coordinating care. This infrastructure may include additional staffing of health coaches or care coordinators, patient activation tools, support for electronic medical record deployment, and more. How CI networks are selecting and deploying these resources is, again, an area we continue to explore.
Increasing similarity to high-performance employed medical groups
Many of the structures and strategies used by mature CI networks bear a strong resemblance to those used by employed physician groups with a track record of clinical and financial success.
The Health Care Advisory Board recently completed a year-long study into the attributes of these "high-performance medical groups," finding many similarities to the strategies discussed above—a high premium on creating a culture of engagement, preferential membership for physicians based on performance and "fit," pursuit of care standardization, increased physician leadership on the inpatient side, and more.
An open question as we continue this research is how these similarities affect operations for health systems that have both a mature CI program and a robust employed group. Are they working to integrate the two networks in terms of organizational structure, leadership, or infrastructure deployment?
Seeking Your Guidance
As this research continues to move forward, stay tuned for more blog posts on these and other topics related to next-generation CI.
How can we make this research most useful to you?
As we speak with mature CI networks, what key questions should we be asking? Is your organization pursuing any of the strategies described above, or doing anything else innovative that we should learn more about? Please let me know by posting a comment here or emailing me directly at firstname.lastname@example.org.