1. What is Mount Sinai Health Partners IPA ("IPA")?
Mount Sinai Health System – Mount Sinai Beth Israel, Mount Sinai St. Luke's, Mount Sinai West, The Mount Sinai Hospital, Mount Sinai Queens, and New York Eye and Ear Infirmary of Mount Sinai – in collaboration with its voluntary and employed providers, has established a clinically integrated network to address the future of health care delivery. Through the establishment of this network by means of an independent practice association, the IPA will improve the quality and efficiency of care provided to our communities and offer meaningful value to payers.
2. What the IPA is not: dispelling the myths:
- It is not an ACO, at this time. The IPA could become or join an ACO in the future.
- It is not taking over your practice or establishing a medical practice of its own.
- It is not a hospital-only organization, nor a physician-only organization; the Board of Managers is comprised of a balance of physician and hospital members.
- It is not a vehicle to enhance or favor one group of physicians over another.
- It is not an instantaneous fix to all the issues facing medicine today.
- It will not seek to manage your day to day operations.
3. Why should I join the IPA?
Collaboration among physicians, hospitals, and other providers of care is essential to achieve the clinical quality and efficiencies necessary to be successful in the future delivery of healthcare. The IPA has been set up to allow the physicians, behavioral health professionals, ambulatory surgery centers, diagnostic and treatment centers, federally qualified health centers, other ancillary providers, and hospitals to work together on clinical initiatives that will lead to demonstrable quality and cost efficiency in the delivery of care. The IPA will provide the breadth, scale and integration of providers necessary to significantly enhance the quality of care and reduce the cost of care that payers are seeking to achieve. The IPA will have the tools necessary to demonstrate to payers the value of the network.
Messenger Model Contracting
4. How will the IPA function initially?
In the short-term while the IPA develops its Clinical Integration ("CI") program, the IPA will offer the services of its provider network, on a non-exclusive basis, to Managed Care Organizations ("MCOs") utilizing a "messenger model" arrangement for purposes of contracting with those MCOs.
Under this arrangement, the IPA may not negotiate the rates on behalf of independent voluntary IPA providers. Rather, the IPA is a conduit of information between the MCOs and the IPA providers. To streamline the contracting process, each IPA provider will provide to the IPA individually determined minimum acceptable fees, and the IPA will provide that information in aggregate to the MCOs. Providers may not share rate information with other IPA providers, and the IPA will maintain the confidentiality of rate information received from each provider and will not share such information among IPA providers.
MCOs are free to accept or reject these minimum rates or propose alternative fees. Individual IPA providers must make their own decisions about whether to accept or reject an MCO offer, independent of whether other IPA providers will accept the offer and independent of any influence or view of the IPA.
5. Can I join other IPAs?
While in the messenger model phase, independent voluntary providers will be free to join other IPAs.
6. What if I want to leave the IPA?
You may terminate your participation in messenger model contracting at any time on 90 days advance notice if you are an independent voluntary provider.
About Clinical Integration
7. What is Clinical Integration?
Clinical Integration may be broadly defined as the coordination of care across people, functions, activities, processes, and operating units to maximize the value of services delivered. A clinically integrated group of otherwise independent providers may contract together with payers if they meet certain conditions, including having a common set of clinical guidelines, a common information technology platform for sharing of clinical information, performance monitoring, and performance incentives.
8. What will a Clinically Integrated network look like?
CI can involve integrated health care provider networks or independent practitioners and facilities that join together to create a program, allowing them to:
- Identify and adopt clinical protocols for the treatment of particular disease states
- Develop systems to monitor compliance with the adopted protocols on both an inpatient and outpatient basis
- Collaborate to encourage compliance with performance improvement processes and protocols
- Enter into shared savings initiatives, care management fees, and other contractual arrangements with health plans in a way that financially recognizes the providers' efforts to improve healthcare quality and efficiency.
9. Is Clinical Integration just another new "buzz word"?
The complexity of healthcare and the unsustainable cost of care have caused both government and private payers to look for new models of care that address increasing value. They are looking to integrated delivery systems that apply population management, eliminate duplication through integration, encourage partnerships among providers, and reward them for improving quality, outcomes, and efficiency. CI is commonly implemented with primary care physicians (“PCP”), physician specialists, and health systems working together; using proven protocols and measures to improve patient care. CI is designed to respond to market dynamics, which are demanding the following changes in how healthcare is delivered:
- Demonstrate improved clinical outcomes and evidence-based care for patients
- Enhance the coordination of care between physicians, hospitals, and other healthcare providers
- Assist with quality reporting and performance
- Facilitate the delivery of the right care, at the right time, in the right setting
- Reduce healthcare costs for patients, employers, and health plans
- Improve reimbursement through demonstration of quality and cost improvement
10. Do government regulatory agencies permit contracting for a Clinically Integrated network?
Antitrust law makes it illegal for independent practitioners to negotiate jointly with health plans unless they are financially or clinically integrated. The government views CI as a way for providers to maintain organized processes to improve the quality of medical care and to control the overall cost of care through increased efficiency and reduction in the amount of unnecessary care provided. An effective CI program contains initiatives that:
- Provide measurable results which are used to evaluate provider performance
- Result in concrete remediation of substandard performance
11. Why does Clinical Integration work?
With CI, a comprehensive network of providers is equipped with the technology, education, and appropriate resources to demonstrate value to the market. The network has the critical mass to manage and improve quality of care for populations as well as individuals through improved access, coordinated care, improved efficiency and lower overall costs of care.
12. Is Clinical Integration already taking place around the country?
Yes. Providers throughout the country are currently demonstrating meaningful results as part of their CI programs. They have shown their ability to improve the patient’s healthcare experience through greater coordination of care; they have reduced hospital admission and readmission rates, they have expanded access to primary care, and have begun to tackle population health.
In addition, CI can help us attract and maintain new market share in a rapidly evolving commercial insurance market. The trend is "narrow network" insurance plans, which offer a lower premium payment in exchange for access to a limited network of physicians and hospitals. Enrollees in such plans must stay within the network. The ability to manage costs and control utilization within a clinically integrated network is attractive to plans building these narrow networks.
13. Is Clinical Integration good business?
Increasingly, providers will be asked about their ability to demonstrate value. Independent practitioners operating their own practices may not have the business scale or capacity to achieve alone what CI allows collectively. CI will allow the organization under which clinical programs are developed, clinical metrics selected, cost savings demonstrated, management of chronic patients improved, communication among providers enabled, and group contracting established to provide gain share for the participants. CI providers will work more collaboratively and be able to position themselves at an advantage in the market based on the value they bring to payers and employers.
14. How does the Supreme Court decision impact the IPA’s plans for clinical integration?
The decision to uphold the individual mandate on health insurance coverage will increase the number of insured, which should translate into less uncompensated care and self-pay patients. To be successful, providers must form and respond as a network to the call by the federal, state and commercial payers for an integrated model of care and prepare to move to these value based reimbursement models. This is the right strategic direction for Mount Sinai Health System and its affiliated physicians and facilities to pursue together.
Clinical Integration at Mount Sinai Health Partners IPA
15. Will participation in Clinical Integration require providers to change the way they practice?
Yes. Providers and their office staff will have to participate in the quality and care management initiatives that are developed to improve patient care and increase efficiency. But, in return, the expectation is that participating providers will benefit financially for achieving performance standards negotiated in CI contracts with payers. The amount of incentive payments will likely depend on both the provider’s personal score and the overall score of the organization. This latter component highlights the importance of providers working together in an interdependent manner to improve care.
16. Who creates the clinical guidelines?
The current plan is for the physicians who participate in the Clinical Integration Sub-committee of the IPA’s Board of Managers to be responsible for the IPA’s development of clinical guidelines. We expect that that Sub-committee will review and approve the use of local and nationally developed evidence-based guidelines and measures. The Sub-committee may also choose to develop additional guidelines with the input of physicians in the appropriate specialties.
17. Will participating providers be required to refer within the IPA's network?
The expectation is that once CI is achieved, providers will refer patients to other providers participating within the network whenever possible. This will ensure that patients cared for by participating providers receive the evidence-based care recommended by the physician-led CI committees. With the tools being developed to share patient information across all participating providers, referring within the network also ensures that relevant clinical data is available at the point of care and reduces unnecessary utilization of services. Of course, given clinical need or patient choice, there will be circumstances when a referral within the network is not possible.
18. How can PCPs partner with specialists and hospitals?
PCP services have been undervalued in the past and poorly reimbursed relative to specialist and procedure oriented services. PCPs have been valued by specialists and hospitals they work with primarily for the referrals and admissions they can generate. Specialists have been valued by hospitals for the high revenue procedures they performed in hospitals. The value provided by PCPs in keeping patients healthy has previously had negative economic value for the volume-driven healthcare provider orientation of the past several decades. As we as a society have begun to realize that there is a limit to the financial resources we are willing to invest in healthcare without demonstration of value correlating directly with quality and inversely with cost, PCPs are beginning to be valued for what they can prevent.
19. What clinical specialties will be needed by the CI network?
A broad spectrum of specialties is essential for a CI network to be able to contract effectively and to be successful in managing care. While any CI network will need to refer out for services not provided by its member specialists or facilities, the more inclusive the network, the better care can be coordinated through communication and sharing of responsibility across specialties and care settings.
20. Will PCPs who refer to me but are not part of the medical staff of Mount Sinai Health System facilities be able to participate in the network?
Being a member of the medical staff of a Mount Sinai Health System facility is a condition of participation in the IPA, but there are categories of medical staff membership at these facilities that recognize that PCPs no longer need to be on the active medical staff of hospitals. If you know of a PCP who might be interested in joining the IPA but is currently not on staff, please contact the IPA.
21. Will the IPA enter into risk contracts with payers?
It is not anticipated or required that the IPA immediately enter into risk contracts with commercial or governmental payers. The IPA will pursue fee for service contracting, and under clinical integration, will seek alternative reimbursement in addition to fee for service, such as pay for performance, shared savings and incentives for demonstrating quality. Contracts that may involve downside risk would only be entertained as the IPA develops the expertise and clinical performance measurement capacity necessary to achieve success under such an arrangement. The IPA's sub-committees and board would evaluate the ability and desire to enter into such contracts in the future.
Membership and Benefits
22. What makes this IPA different from other IPAs in Manhattan?
Mount Sinai Health System has embarked upon a number of integration and quality initiatives that will serve as the building block to differentiate the IPA from others in Manhattan. The medical home initiative, the introduction of a health information exchange ("HIE") for the sharing of patient data, and the development of clinical guidelines for quality measurement and improvement are a few such efforts. The IPA is committed to moving to a CI model; our work to date helps lay that foundation. In addition, we will offer credentialing services as a benefit of participation to help alleviate the administrative burden practices face in complying with different organizations’ and payers’ requirements.
23. Can I join other IPAs?
Once CI is implemented, we are seeking the commitment of providers to participate solely with the IPA. This will allow the CI program to maximize benefits for patients and participants while helping us oversee quality and minimize the cost of care.
24. How much does it cost to join the IPA?
There will be no up-front capital requirement or membership fee requested of individual providers. The IPA will charge participants annual dues. Initially dues have been set at $250 per year, but dues may be subject to change by the IPA Board in the future.
25. How do I join the IPA?
Providers wishing to join the IPA will complete and sign an application and the participation agreement, then return them to the IPA for processing.
26. What services will the IPA provide?
- Coordinate registration and credentialing services for providers for their participation in managed care contracts and their work at Mount Sinai Health System hospitals and facilities.
- Serve as a central point of communication, information and resource to participating providers.
- Aggregate and share patient health data among providers through a health information exchange.
- Measure with electronic tools the quality and efficiency of the participating providers across the ambulatory and inpatient environments.
- Provide clinical decision support to proactively reach out to members in need of care.
- Once clinically integrated, negotiate with payers on behalf of IPA providers.
- Explore with payers alternative reimbursement programs, including pay for performance, shared savings, program development funding, and methods to recognize care coordination activities.
27. What does joining the IPA mean for my practice?
In joining the IPA, providers will commit to adhere to the requirements of the participation agreement. These requirements include, but are not limited to, following evidence-based clinical guidelines adopted by the IPA, sharing electronic patient data with the IPA to facilitate quality benchmarking and measurement; and participating in continuing medical education for providers and staff.
28. Must all the physicians in my practice join the IPA?
Voluntary independent physicians in a group practice are not required to join the IPA when others in their practice elect to join, at least not initially. Ideally, as we move toward CI, it will be beneficial to have all providers in a practice participate, recognizing the value of an integrated model and leveraging tools to reduce practice variation.
29. Will providers who are members of my practice group, but not on the medical staff, be able to join the IPA?
All IPA participants must meet eligibility requirements, including being credentialed and having a medical staff affiliation with a Mount Sinai Health System facility. Additional information on becoming a member of the medical staff is available from the IPA.
30. What if I already participate in a managed care organization ("MCO")?
Existing MCO contracts in which you currently participate likely reimburse you on a fee-for-service basis. In the coming years, we anticipate movement away from fee-for-service reimbursement into value-based payment. We believe working in a collaborative manner as a group of providers best prepares you for the future.
31. What if I want to leave the IPA?
Under CI you may have to continue to participate in certain payer contracts for a given amount of time or until the end of a contract year, but that would be determined based on the terms of the payer contract.
32. Can Clinical Integration impact reimbursement to providers?
Yes. The result of this demonstrated value to payers in the market often creates economic benefits to all parties that otherwise would not be lawfully permitted, such as the distribution of shared savings.
33. What is the benefit for practitioners in partnering with a hospital system?
Most practitioners are in small, unaligned practices. Unaligned practitioners will have limited ability to affect cost, quality, and outcomes; therefore, will be unable to show value to the payers. If the hospital system and practitioners share the same vision, partnering with a hospital can provide distinct advantages. The hospital system can provide structure and financial backing required to get the network started and to help implement programs. These efforts demonstrate to payers and the community as a whole that the CI program is both legitimate and valuable. Integrated networks can provide individual and small groups of practitioners with the tools and organization needed to support their practice. It should also be mentioned that achieving the best quality of care for a population cannot be done solely on either the outpatient or inpatient side.
34. Will employed physicians be members of the IPA?
Yes. The hospital employer will likely execute a single signature participation agreement for all its employed physicians. Employed physicians will also be eligible for IPA Board seats and committee membership. They will be full members of the IPA and full participants in the CI program and included in CI contracts with payers.
Information Technology ("IT")
35. Do I need to have an electronic health record ("EHR") system in my office to join the IPA?
No. Not at this time, but you will need to have high speed internet in all offices to access the health information exchange ("HIE") used by the network to share information on patients and on performance. Practices are encouraged to implement an EHR before the federal penalties regarding meaningful use of EHR and Centers for Medicare & Medicaid Services ("CMS") reimbursement come into play in 2014. Implementing EHR in combination with an HIE allows providers to collaborate in the care of their patients, to share important clinical data, and to reduce duplication of services that adds unnecessary cost to our healthcare system.
36. How will the IPA help providers with information technology?
Clinically integrated organizations not only follow standard clinical guidelines for service and treatment, but also have a reliable means of ensuring physicians have up-to-date, relevant clinical information on their patients. Health information technology ("HIT") provides physicians with a powerful toolkit to enhance patient care.
The HIE will expand the available data on patients by facilitating exchange of information with other providers’ EHRs and data sources, such as laboratories. This allows physicians to treat patients with the most information possible from a variety of sources. Additionally, these HIT systems integrate with reporting software that will produce reports measuring quality indicators and how they change over time.
37. Will the Mount Sinai Health Partners IPA Provide HIT Software and Support?
Many physicians employed by a Mount Sinai Health System hospital may already be using the eClinicalWorks EHR, and those systems will be connected to the Health Information Exchange as part of our investment in HIT.
For independent physicians who already use other electronic health records, there will be a means by which those EHRs will be connected to the HIE, making data available to other physicians in the network. For those independent physicians who do not already use an electronic health record, there will be options available to choose and implement an EHR that can connect to the HIE. Details on the process for these connections and systems and their costs will be made available through the IPA.
38. What data will the IPA collect and how will it be used?
The IPA will collect registration information to manage the provider membership of the organization and to coordinate credentialing.
Clinical data associated with key measures that the IPA will use to demonstrate clinical value and efficiency will be gathered and aggregated. This data will also enable clinical decision support tools, performance reporting and calculation of potential distributions through pay for performance or shared savings programs.
This data sharing approach puts network wide information in the hands of the organization that represents you so the IPA may effectively demonstrate quality and value. It will enable the IPA to give you feedback and tools, and to identify opportunities for quality improvement and efficiency.
to see submission forms.