Physician Care Alliance Clinically Integrated Network

Q: What is Physician Care Alliance?

A: Physician Care Alliance (PCA) is a Clinically Integrated Network, which represents an ongoing collaboration among providers to improve patient care outcomes, quality, and efficiency. PCA is a physician-led, physician-driven interdependent care delivery system that combines the latest in evidence-based best practices with innovative data and analytics technologies.

Our focus is on sustainable arrangements that align quality incentives and total cost of care with PCA’s Quality Program. As a result, participation in PCA provides physicians with opportunities to collaborate to achieve higher quality and greater cost-effectiveness than they likely could accomplish on their own.

Q: What does clinical integration mean?

A: According to statements of the Antitrust Enforcement Policy in Health Care by CMS, evidence of clinical integration includes “…an active and ongoing program to evaluate and modify practice patterns by the venture’s providers and to create a high degree of interdependence and cooperation among the providers to control costs and ensure quality.” The Federal Trade Commission in its policy statements around clinical integration and financial risk sharing arrangements goes further and states that provider organizations must improve efficiencies by monitoring and controlling quality and cost as evidenced by: 1) use of evidence based clinical guidelines, standards, and protocols; 2) investment in economic and human capital; and 3) enhanced application of information technology.

Through a feasibility study completed in May 2013, PCA identified an approach to achieve clinical integration while establishing a network that meets the requirements as outlined by the Centers for Medicare and Medicaid Services (CMS) and the Federal Trade Commission.

Q: What clinical initiatives will the PCA Clinically Integrated Network include?

A: PCA’s overarching goal is to enhance the quality and efficiency of the services that participating providers deliver to patients. The PCA Board, committees and staff will adapt and improve the network based on physician feedback and ongoing analysis of quality and cost data. Components of this continuously developing and evolving network include:

  • Evidence-based medicine and quality reporting
  • Practice transformation for chronic, acute, and preventative clinical initiatives
  • Care Coordination and Care Management programs
  • Team training for patient-centered care
  • Population health management tools, data, and analytics
  • Risk stratification and data aggregation for clinical outreach and engagement activities
  • Communication among primary care physicians and specialists
  • Community resource integration

PCA will measure performance of the network’s initiatives through various sources, including: claims processing and adjudication systems, practice management and scheduling data, disease registries, pharmacy benefit data, and hospital, physician, and ambulatory EMR data.

Q: What are the benefits of participating in PCA’s Clinically Integrated Network?

A: Provider groups that have already signed up to participate in PCA are doing so for a variety of reasons, including:

  • Enhanced physician leadership over clinical decisions through selection and implementation of evidence based clinical protocols
  • Decision making participation on committees and influence on PCA Board decisions
  • Meaningful clinical integration initiatives that span the entire continuum of care, thus enhancing the value to all participants
  • Access to population health management tools with training and administrative services that streamline data compilation and extraction for quality metrics management as well as compliance with adopted protocols
  • Value based care and risk adjusted coding training and resources
  • Access to training to maximize organizational opportunities of Care Management and Utilization Management to improve processes and outcomes around hospital admissions/readmissions, emergency department, pharmaceutical services, and transitions of care
  • Data analytics support and reporting capability to monitor and improve cost efficiency to impact total cost of care
  • Physician-directed contractual arrangements that recognizes the physicians’ efforts to improve health care quality and efficiency
  • Collaboration with PCA in initiatives which provide true community benefit

Q: What is expected of physicians participating in PCA?

A: PCA is interested in mutually beneficial relationships with participating groups, so we encourage an open dialog with our team members about the requirements for participation as well as the group’s current capabilities and interest in improvement. The basic requirements for participation include:

  • Physician organization representatives must sign a Network Participation Agreement.
  • Physicians will collaborate with physician colleagues and PCA in the development and adoption of clinical initiatives that enhance the quality, service, and cost-effectiveness of patient care.
  • Physicians will review their data on a defined schedule for data-driven quality improvement and cost efficiency. Physicians are encouraged to participate in the committee measure selection process for their specialty.
  • Physicians must use an ambulatory EMR as a prerequisite for the development of clinical integration. PCA is working with software vendors who have streamlined the data collection process to make it as non-intrusive as possible on practice operations. In addition, a physician must have access to high-speed internet and the ability to submit claims electronically.
  • All physicians participate in PCA’s Quality and Care Management initiatives.
  • Physicians will hold themselves and each other accountable for compliance with PCA’s network clinical integration program, including meeting performance measures thresholds. In the event that minimal standards are not met, the physician will be required to participate in PCA training, committee review, and if necessary, remediation and disciplinary efforts.

Q: Does participating in PCA guarantee better health plan contracts for physicians?

A: Participation in the PCA network gives provider groups a voice in the contracting process. A clinically integrated foundation allows PCA to approach health plans on behalf of participating providers in a legal and appropriate manner. Our contracting process has produced beneficial contracts that align health plan and network incentives.

Q: By agreeing to participate in PCA, will participating groups have to abandon their current health plan contracts?

A: The answer depends on the physician group’s existing contracts. If a group does not have a value-based or shared-savings contract, the PCA contract generally overlays the existing contract leaving its provisions in place. If there is a current, conflicting contract, then it is possible that the PCA contract may supersede or replace the existing contract. In either case, the underlying fee schedule remains intact. PCA can help explore the implications of various existing health plan contracts.

Q: Is there an opt-out option for physician organizations?

Physician organizations can opt out of participation in the PCA CIN in its entirety with written notice, as defined by the PCA Participation Agreement.

Q: Why might physicians want to consider participating in a Clinically Integrated Network?

A: There is a growing number of physicians nationwide joining Clinically Integrated Networks as part of their overall business and health care strategy because they believe in the value proposition:

  1. Clinically Integrated networks generally strive to ensure that quality and efficiency objectives are aligned with participating physicians and they can prove to be a powerful ally and advocate on physicians’ behalf.
  2. Clinical integration allows physicians to: (a) demonstrate their quality to current and future patients, (b) choose the clinical measures against which they will be evaluated, (c) develop programs for better management of chronic patients, (d) gather collective support for building necessary infrastructure, (e) engage in group contracting, and (f) position themselves at an advantage in the market on the basis of quality.
  3. Clinical integration gives physicians the ability to (a) demonstrate their quality to current and future patients; (b) enlist physician support for initiatives, including measure compliance, clinical pathways, and standardized order sets, (c) develop a better, more collaborative relationship within their provider organization; (d) improve performance on quality measures; (e) position themselves at an advantage in the market on the basis of quality.
  4. Clinical integration provides patients with: (a) better value for their health care dollar; (b) more effective care management and outreach from their healthcare team; (c) more reliable information to support their choice of health plans, physicians, and hospitals; (d) more accurate and meaningful provider ratings; and (e) greater stability and longevity in their relationship with their providers.
  5. Clinical integration gives employers: (a) the ability to more effectively manage the health care costs of employees and their dependents through the purchase of better, more efficient health care services; (b) increased employee productivity and reduced absenteeism through the better management of chronic disease; (c) lower health care costs over the long term through the reduction of variation in physician practice patterns; and (d) more reliable information to support conversion to consumer-driven health insurance products.

Q: How can I receive more information regarding the details of PCA’s Clinically Integrated Network?

A: Please request more information from PCA by calling 206-320-6159 or emailing pcaadmin@polyclinic.com. We are happy to meet with physicians interested in learning more about our clinical quality and cost initiatives or with those wanting to discuss, learn, and share more information about value-based contracting, clinical integration.