Clinical integration is collaborative, coordinated care among health care providers. The focus is on improved quality, increased efficiency, and reduced costs. A clinically integrated network may include physicians, acute and post-acute facilities, home health practitioners, and other health care providers. Clinically integrated networks develop clinical protocols, measure performance against the protocols, build care management systems to engage patients, implement technology to support these initiatives, and reward providers for high quality care. As a result, communities become healthier, patients are more engaged, and health care is better coordinated.
Payment models continue to move from fee-for-service payments to value-based contracts that share savings and risk. Clinically integrated networks provide the infrastructure for value-based contracting through technology and systems designed to reduce variation in care, manage chronic disease and coordinate care across the continuum.
As St. Luke’s Care Network (SLCN) receives shared savings payments from value based contracts with payors and purchasers, the incentive payments will be distributed to physicians and other participating providers based on quality and efficiency, and the SLCN incentive distribution policy.
Among other benefits, participating physicians will have access to:
- Clinical protocols that are developed by their local colleagues;
- Care management resources that engage high risk patients with chronic illnesses;
- New payment models with financial incentives for quality outcomes; and
- Participation in a preferred network.
Among other requirements, participating physicians;
- Participate in quality and cost improvement programs that include sharing data with St. Luke’s Care Network;
- Comply with certain eligibility criteria;
- Support care management programs developed by St. Luke’s Care Network;
- Abide by policies, procedures, and performance standards adopted by St. Luke’s Care Network;
- Obtain and maintain participating provider status with contracted purchasers;
- Appoint St. Luke’s Care Network as its agent to negotiate certain contracts; and
- As requested, actively participate in the St. Luke’s Care Network committees.
A goal of St. Luke’s Care Network’s program of clinical integration is to ensure that patients of participating providers have the benefit of the program’s quality initiatives through their continuum of care. Accordingly, for members of plans contracted with St. Luke’s Care Network, participating providers shall endeavor to utilize the resources of, and refer patients being treated pursuant to and within the scope of such contracts, to other St. Luke’s Care Network participating providers, in accordance with St. Luke’s Care Network policies.
St. Luke’s University Health Network (SLUHN) has invested funds in the infrastructure and operation of St. Luke’s Care Network. St. Luke’s Hospital of Bethlehem is the sole member of St. Luke’s Care Network. Physicians and other healthcare providers participate in St. Luke’s Care Network through participation agreements. As requested, participating physicians are expected to contribute to SLCN through service such as membership on committees, developing clinical protocols, and recommending best practices that improve St. Luke’s Care Network’s success.
Participating providers will not be permitted to enter into a contract with a payor if St. Luke’s Care Network, at that time, already has a contract covering that same health benefit plan, program or product. Participating providers may enter into, independently of St. Luke’s Care Network, any contract with a payor covering any health benefit plan, program or product that a St. Luke’s Care Network payor contract does not cover.
While your current contracts may remain for a period of time, they may be replaced by St. Luke’s Care Network payor contracts upon renewal.
St. Luke’s Care Network is the “in-network” network for the 23,000 members of the St. Luke’s University Health Network employee health plan. Providing care to the SLUHN employees demonstrates St. Luke’s Care Network’s effectiveness in improving outcomes and reducing costs.
St. Luke’s Care Network may negotiate contracts for the upside or shared savings component only, or St. Luke’s Care Network may negotiate for the base fee component of services, which may include both upside and downside risk.
St. Luke’s Care Network will not negotiate third-party payor contracts on behalf of its network of participating providers until it has determined that those negotiations are pursuant to a program of clinical integration or substantial financial risk sharing.
Participation requires physicians to support St. Luke’s Care Network quality goals, utilize clinical protocols, and meet standards of performance that are developed by St. Luke’s Care Network clinical committees.
In-network referrals assure that patients receive the consistent care that is included in physician developed clinical protocols. Also, in-network referrals support sharing of patient data, leading to more coordinated and efficient care.
Shared claims and data supports care coordination across the continuum and provides the method to assess outcomes. In the absence of a shared electronic medical record, clinical information can be viewed via EpicCare Link, and data can be submitted to SLCN via fax or to a secure web site. Examples of EHR data that may be collected includes BMI and BP measurements.
Aggregate data will be used by the St. Luke’s Care Network leadership and clinical committees to measure the success of the clinical programs and to identify opportunities to improve care. Individual physician results will be reviewed to evaluate opportunities to improve the overall performance of St. Luke’s Care Network. Periodically, participating physicians will receive individual or practice outcome reports.