TCIH will primarily enter into agreements that have quality and utilization incentive goals. If you achieve the goals, you will receive incentive payments. The contracts you have with existing payers will remain in place. In the future, the TCIH clinically integrated network may also accept risk, either sharing in the savings if costs are reduced, or sharing in incentives from improvements in quality and efficiency with bundled payment and capitated contracts. As a hospital-sponsored network, TCIH has the additional ability to develop hospital quality and efficiency programs in house that do not depend upon payer involvement to generate savings and income.
Physicians and providers who align with hospitals to provide value-based care can more effectively manage the total cost of care for a population. Already, employers and insurance companies (payers) are seeking full-service partners who represent all or most of the continuum of care to create high quality provider networks. Most payers place great emphasis on their relationships with hospitals and seek to deepen them by supporting clinical integration programs that yield value for their customers. Additionally, Martin Health is one of the top employers in Martin and St. Lucie counties, and will encourage its employees (through its benefit plan) to seek out care from physicians participating in TCIH. Moreover, as a hospital-supported network, TCIH can align processes and incentives around inpatient quality and efficiency programs that can benefit physicians directly as well as the performance of the overall network.
Will the TCIH network help me with MIPS, MACRA and Quality Reporting?
Yes, participation in the Medicare Shared Savings Program, in any track, has benefits over reporting quality to Medicare independently. Likewise, insurance plans tend to work closely with clinically integrated networks on quality reporting in commercial shared savings programs which reduces the need for physicians and providers to report individually.
Measurements of Success
If the following milestones are achieved, TCIH will have positioned itself for success in the healthcare reform era:
- Enter into participation agreements with a significant number of providers where the provider(s) agree to comply with clinical guidelines and be clinically integrated with TCIH.
- Implement systems that will enable TCIH to measure and report to all constituencies: financial, quality and utilization performance.
- Establish major diagnosis/disease state evidence-based clinical guidelines that are cost effective without sacrificing quality.
- Develop mutually acceptable shared financial goals and risk/incentive systems to reward members for great outcomes.
- Demonstrate with data that TCIH patients have value-based care, better patient care experiences, are healthier and pay less for their care.
- Pursue value-based reimbursement contracts with employers and health insurance providers that lead to incentive payments for TCIH providers.
How will TCIH change the way I practice medicine?
Over time, it is expected all TCIH members will share information through technology platforms that will provide access to data about your patient population you don’t already have. You will be asked to use evidence-based protocols endorsed by your colleagues within TCIH for certain common diseases when possible and review your patients’ data as part of your practice pattern to ensure that your patients are receiving all of the care needed for their conditions. We believe that healthcare in the future will require much more teamwork and interdependent activities. In so doing, local and national measures of quality will improve in your practice.
What medical record data will I be required to share with TCIH?
TCIH members will be required to contribute some patient information in the course of coordinating care with other TCIH providers. Most of the data, such as diagnoses and laboratory information, should come from other electronic systems including claims systems.
When will TCIH enter into risk contracts?
Initially, TCIH is not expected to enter into risk contracts, but will evolve with incentive contracts as the informatics infrastructure and expertise develop within the TCIH network. One exception may be the Medicare Shared Savings Program Track 1+, or others if it is felt TCIH can perform well in the program and take advantage of the benefits of participation to its providers under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Most early pay for performance contracts will have only potential for gains and pay for performance shared savings arrangements.
Will TCIH apply to become a Medicare ACO?
TCIH is seeking to participate in the Medicare Shared Savings Program Track 1. One benefit of a hospital-sponsored network is the fact that existing relationships with major commercial insurance providers pave the way for full-service commercial ACO contracts.
Will there be reimbursement reform (i.e. pay for performance, bundled payments, episodic payments, capitation)?
Eventually, TCIH will seek contracts with the value proposition that could include bundled payments, episodic payments, or capitation. Hospital Quality and Efficiency Programs (HQEP) can be structured around episodes, bundles or other mutually agreed upon measures of quality and efficiency. The initial focus of TCIH’s contracting will be contracts that have only upside potential to its members. Later, as TCIH matures in its informatics and quality capability, more complex incentive contracts would be considered based on the needs of payer and employers.