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Clinically Integrated Networks – The Future Angel Amongst a Bevy of Devils

22 Jan 2016 5:33 AM | Anonymous

By Dr. Jay Greenstein 

Clinically Integrated Networks.pdf

It was 2007, I was sitting in my office one day, and I was just fed up. I mean like SUPER-PISSED fed up. We were having yet another issue with an insurance company not paying our bill for some stupid denial code, when there was no mistake on our part. The carrier was just playing “deny and delay”. I was a (basically non-active) member of the Maryland Chiropractic Association at that point in my professional career, but I called up the MCA home office and just started... well... going off... “What is the MCA doing about this?!?! This is ridiculous!!!” I’m sure I said a few other words not suitable for this esteemed, national publication, but let me tell you, I was holding nothing back. What was the response to my little hissy-fit rant? I’ll get into that in a moment, but let me just say that it changed my life forever... “Well, Dr. Jay, there’s an insurance committee meeting at Dr. Spector’s house in Baltimore tomorrow night, if you’d like to go there and find out.” Now, I live about an hour from Dr. Spector, and the last thing I wanted to do was to schlep up to Baltimore after a busy, stressed-out day in practice. But, you know what? Driving to Baltimore was less painful than me having to deal with these insurance issues for the rest of my life. I needed to find out what was going on!

The next night, I got to Dr. Spector’s house and although I knew some of the MCA board members, I wasn’t close with any of them. (Like I said, the response to my rant changed my life forever. And for the better I might add... a whole lot better. I would go into battle with my state association comrades any and every day of the week, and I can say that honestly, because it’s what we do)... So, in the beginning, I just sat back and listened. Here’s what I learned at that meeting about the insurance companies and our associated issues. They have a lot of money and power, and we were basically pawns in their “stock price” and “earnings” game. The more challenges they threw at us, the better off they were... and the worse off we were. We were all individual doctors and they were one huge conglomerate with enormous resources. Now, I know you’re reading this right now saying, “Jay, you’re an idiot...you didn’t know that???” Yes, I knew it, but it hit home for me more because each doctor at the table had their OWN set of issues. In other words, while some issues were shared and global, others were random, yet still painful to the doctor dealing with them.

Fast Forward #1: I became Insurance Chairman for the MCA about 30 days later.

Fast Forward #2: I became Insurance Chairman for the Virginia Chiropractic Association not long after (my practices border the District of Columbia so it made sense).

Fast Forward #3: After multiple fee schedule REDUCTIONS from the two largest carriers in our region, I realized we needed to do something more than just fight the typical battles we fight on a daily basis with our insurance company “partners”.

Fast Forward #4: With the support of both state association boards, in 2011, we created a CHIROPRACTIC STATE ASSOCIATION OWNED Independent Physician Network – The East Coast Associations’ Independent Physician Network (ECAIPN). Important note: many of the existing networks out there that doctors struggle with on a daily basis are privately owned – they are either part of a larger insurance company or individual owners are flying around in private jets while we struggle to make payroll. The difference in what we did in Maryland and Virginia is that we modeled our organization after a very successful CHIROPRACTIC STATE ASSOCIATION OWNED Independent Physician Network, SecureCare. SecureCare was started many years ago by visionary DCs in Nebraska who saw that there had to be a better way. Since they were owned by the actual Nebraska Chiropractic Physicians Association, they had their members’ interests first. And of course their values aligned with doing the right thing by the patients, the public, and the healthcare system at large, which is why they have become very successful and have grown outside of just Nebraska.

Present Day:  While we created the legal entity, we were not yet operational. Why? Well, we did a lot of due diligence to ensure that we were set up correctly and around how we were going to run the network. So, after discussions about direction, and aligned values and goals, it became clear. A joint partnership with SecureCare was in order. In July of 2014, the ECAIPN signed an agreement with SecureCare for SecureCare to be our network development partner.

Why am I telling you all this? Why do you care? Because healthcare is changing more rapidly than anything I’ve seen in my 20+ years of practice. If you don’t know what the future holds, you are toast. And I mean burnt toast that crumbles when a soft breeze blows over it.

So, here’s what you need to know. Do you remember the article I wrote a year ago “Making Sense of Healthcare Reform?” I talked a lot about new delivery models. One delivery model I didn’t talk about was a Clinically Integrated Network (CIN). Did you ever wonder why hospital systems can negotiate fees with the insurance companies on behalf of all their providers? Why are a group of quasi-independent doctors allowed to do that and we’re not?!?!

It’s because hospital systems are clinically integrated. What does a clinically integrated network look like? According to URAC, an organization that accredits CIN’s, “Clinical integration is the coordination of patient care across conditions, providers, settings, and time to achieve care that is safe, effective, efficient, and patient focused. Smaller systems of care come together to form larger systems of care that broaden the purview of provider networks, ensuring dependable linkage between care settings and conforming enhanced coordination, and consistent use of evidence-based guidelines for managing patients.”1

In a recent post from the law firm OberKaler, the anti-trust exception (negotiating fees for the group of doctors – typically an anti-trust violation) in a specific example of a clinically integrated network was explained: “As a result of this clinical integration program, the FTC concluded that, although joint contracting by physicians generally constitutes price-fixing, which is a per se violation of the antitrust laws, the Norman Physician Hospital Organization (PHO) qualified for rule-of-reason analysis. Importantly, the advisory opinion stated that ‘Norman PHO’s proposed joint contracting appears to be subordinate to the network’s effort to improve efficiency and quality through the clinical integration of its participating physicians,’ that is, the joint contracting is an “ancillary” (i.e., reasonably necessary) component of the clinical integration initiative. The FTC further stated that the PHO’s proposed activities appeared ‘unlikely to unreasonably restrain trade’ based on a number of factors.” 2

So what does all this mean? It’s simple! When a CIN has been established correctly, it can be exempt from anti-trust regulations, and therefore fee negotiation for a group of doctors can occur, and it won’t violate anti-trust. Now, I said “simple” and that is the “simplistic” version, but the concepts are on target.

The Future: SecureCare, the only CHIROPRACTIC STATE ASSOCIATION OWNED INDEPENDENT PHYSICIAN NETWORK, understands the importance of clinical integration. They are the angel in a universe of Devils. They understand that if we do the right thing by patients AND the system, by providing the best, evidence-based care, at the lowest cost and at the highest levels of patient satisfaction, there should be a reward for that. Their network has yielded rewards for the doctors in Nebraska for a very long time.

Other PRIVATELY owned companies (aka, “Devils”) are working towards clinical integration. Do they believe doctors should be rewarded for the great outcomes they achieve? Or will they pocket the extra cash so their parent company’s stock price goes up, or the CEO can buy the newest $48 million dollar Bombardier Global 5000 private jet?

To be clear, I have nothing, literally nothing, to gain by singing the praises of SecureCare. We, the ECAIPN, are THEIR customer. They are working for us, so make no assumptions as to why I am undoubtedly singing their praises. I am doing so, for three reasons:

  1. They have a track record of success in helping their state associations and their doctors become more successful while partnering with the insurance companies so that everyone gets a “win”(especially the patient!).
  2. They see the future of healthcare and their strategy is to ensure chiropractic’s rightful place in it.
  3. There are Devils out there who are also touting that they are developing a CIN. If you make a deal with The Devil, well, we already know your fate...


Sources:
1. https://www.urac.org/accreditation-and-measurement/accreditation-programs/all-programs/clinical-
integration-accreditation/


2. http://www.ober.com/publications/2104-ftcs-norman-pho-advisory-opinion---new-clinical-integration-
guidance-same-antitrust

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