Business Model & Incentive Plan
Will participation in THN require physicians to change the way they practice medicine?
To some extent, yes. Participation in the quality and care management initiatives of the THN Clinical Integration Program will require time and attention from physicians and their office staff. In return, participating THN physicians will be eligible to obtain financial rewards for their achievements through the Clinical Integration Program, funded by contracted health plans and employers. Both the initiatives and the amount of incentive payments will be determined and managed by THN physicians.
Will I be financially rewarded for participation in THN?
Each year, a sub-group of the Operating Committee create, and the entirety of the Operating Committee approve, an incentive plan. These plans are geared towards improving quality and access while reducing costs to the network. Each physician will be responsible for completing certain criteria to earn 100% of your yearly incentive.
What services does Care Management give patients?
Care Management provides collaboration with your team of providers, chronic complex care management, disease management, readmission prevention and care transition, community resource referral, medication review and reconciliation, medication assistance program, drug information to providers and care managers, patient education, review and enrollment in Medicare Part D plans, 24-hour nurse access line, advance care planning, and compassionate care/end-of-life transition.
Who is eligible for Care Management services?
Those patients with a THN primary care provider covered under a contracted payer (Traditional Medicare, Humana Medicare, United Healthcare Medicare, Cone Health UMR plan, and HealthTeam Advantage Medicare), has an HCC of 6 or greater (or 2+ hospitlizations in 6 months or 10+ ED visits in one year) with a targeted diagnosis of heart failure, COPD/pneumonia, hypertension, diabetes, and/or depression.
What characteristics should the patient referral have?
You could consider sending your patients to THN Care Management if they: have a chronic health condition with daily management challenges, have poor health literacy and/or problem solving skills, have polypharmacy/medication barrier issues, have family health education deficits, lack social support, are not safe to remain at home or need referrals to community resources for social needs.
What is clinical integration?
Clinical integration is an effort among physicians, often in collaboration with a hospital or health system, to develop active and ongoing clinical initiatives that are designed to control costs and improve the quality of health care services. Participation in an effective clinical integration program will provide independent physicians the ability to contract collectively with insurers and employers without violating antitrust laws.
What are the characteristics of effective clinical integration initiatives?
An effective clinical integration program will contain initiatives that (1) provide measurable results which (2) are used to evaluate physician performance and (3) result in measurable improvement in the quality of patient care.
Why are physicians across the country engaging in clinical integration?
Physicians have numerous and overlapping motivations for joining together in clinically-integrated networks like THN, including: (1) to enhance the quality of the care provided to patients, (2) to legitimately negotiate with payers as a network, (3) to respond to health plans that are under tremendous pressure to use “report cards” that exclude “inefficient” physicians, (4) to provide access to technological and quality improvement infrastructure that will allow physicians to have ownership of the quality data to insure accuracy of any “report card” generated, and (5) to allow networks of physicians and hospitals to market themselves on the basis of quality.
Cone Health Partnership
Do I have to be a Cone Health employee or affiliated physician to be a part of THN?
No. Although Triad HealthCare Network is a subsidiary of Cone Health, over 60% of our practices and providers are not directly affiliated with Cone Health.
By agreeing to participate in THN, will practices be required to abandon medical staff appointments at non-Cone Health System hospitals or admit patients only to Cone Health System hospitals and ambulatory care facilities?
No. THN is a non-exclusive organization, making no limitations whatsoever on a physician’s ability to admit patients to non-Cone Health sites of care.
Can Cone Health gain control over my practice when I join THN?
Absolutely not. THN is a physician-led initiative. Physicians in private practice who choose to participate will maintain their practice status. It is important to note that more than half the physicians on the THN Operating Committee which led the development of THN are independent and are actively involved in setting the direction of our organization.
What role will physicians employed by Cone Health play in THN?
The physicians employed by Cone Health are expected to participate in THN and become early adopters of the collaborative behaviors needed to drive quality and cost improvements. However, THN requires that governing committees to maintain balanced participation between employed and independent physicians and between primary care and specialist physicians.
Medicare & Next Generation ACO
What is an Accountable Care Organization?
Accountable Care Organizations, or ACOs, are groups of doctors, hospitals, and other health care professionals, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care may include talking with your different medical providers to manage your medications and may also include providing you with certain preventive care services. ACO services vary but can include providing transportation for doctor appointments or providing you with a list of resources in your community where you can get other services you may want or need.
I’ve never heard of a Next Generation ACO- What is that?
The Next Generation ACO Model is an initiative for ACOs that are experienced in coordinating care for populations of patients. It will allow these provider groups to assume higher levels of financial risk and reward than are available under the other programs. The goal of the Model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for Original Medicare beneficiaries.
What is the Telehealth Waiver?
Current Medicare regulations limit the use of telehealth services to those in rural areas or patients who have spent recent time in a specific type of health care facility. The Next Generation ACO telehealth waiver eliminates both the originating site requirement as well as the rural requirement and allows an aligned Next Generation ACO beneficiary to receive telehealth services in their home whether they are in a rural area or not.
What is the Post-Discharge Home Visit waiver?
Medicare Fee-For-Service beneficiaries today can receive post-discharge home visits when they return home after discharge from an inpatient facility (this service is not a home health service for the home bound) from a physician. The Next Generation ACO Model waiver eliminates the direct supervision requirement and allows for a physician to contract with licensed clinicians to provide a home visit to a patient at the patient’s home, under the general supervision of a Next Generation ACO Participant or Preferred Provider (a Next Generation Participant or Preferred Provider is a physician that is part of the Next Generation ACO or has agreed to work with the ACO) following discharge from an inpatient facility. This waiver provides flexibility during the critical time when a Medicare beneficiary is discharged from an inpatient facility. The waiver is available to approved Next Generation ACO Participating Providers and Preferred Providers for their aligned beneficiaries to use if:
The beneficiary does not qualify for Medicare coverage of home health services;
The services are furnished in the beneficiary’s home after the beneficiary has been discharged from an inpatient facility; and
The services are furnished not more than once in the first ten days following discharge and not more than twice in the first thirty days following discharge.
What is the Three-Day Skilled Nursing Facility Waiver?
This Medicare beneficiary service allows Next Generation ACOs and approved skilled nursing facilities (SNFs), or short-term nursing facilities, a waiver of the Medicare rule requiring a three-day stay in an inpatient hospital, acute-care hospital, or critical access hospital (CAH) prior to admission to a skilled nursing facility. In other words, this waiver allows for a Medicare patient, aligned to a Next Generation ACO that is participating in the waiver, admission to approved SNFs from their home, a physician’s office, or an observation status in the emergency room; or when they have been in the hospital for fewer than three days.
Can Medicare change my doctor or force me to see another doctor in this network if I am aligned to Triad HealthCare Network?
No. You are aligned to Triad HealthCare Network through your primary care provider and this does not affect your Medicare benefits in any way. You can always see any doctor you choose that accepts Medicare.
Within THN, will physicians be involved in the development of clinical integration and the leadership of this company?
Yes. THN was developed by a number of physician leaders in the community in partnership with Cone Health. THN is governed and operated by a physician-led Board of Managers and Operating Committee, which includes both employed and independent physicians.
What geographies does THN cover?
Currently we cover Guilford, Rockingham, Randolph, Alamance, and part of Forsyth counties.
What are the benefits of being a member of THN?
Network referrals, PQRS eligibility, Care Management for your highest at-risk patients, education on coding and payment reform (such as Risk Adjustment Factor Coding), automatic qualification for Advanced Alternative Payment Method under MACRA ruling.
What if I am not on an EMR?
THN has partnered with KPN Health Analytics to work with 30+ EMRs to support connectivity and performance reporting. Since EMR is a requirement under MACRA, all members of THN must be on an EMR by January 1, 2018 or be following steps to enroll at that time.
What are Divisions?
The purpose of the Division is to provide an avenue of communication between Physicians, THN and North Texas Specialty Physicians. Meetings are to help provide a forum for Physicians to discuss quality and fiscally-responsible healthcare for the benefit of physicians and their patients. Topics may include claims processes, Utilization and Care Management, Quality Measures, Finances and specific divisional issues.
What are CPCs?
A multi-disciplinary group from each specialty, who primarily focus on quality outcomes and disease-population projects for THN and Cone Health.
What can I do as a specialist to help THN?
Specialists play a major role in the success of THN. Communicating your findings and recommendations back to primary care referring providers. This assists in gathering metrics data as well as keeping the healthcare team “on the same page”. Another way specialist can assist is through thoughtful coding. With risk adjusted payments on the horizon, documenting the acuity of the patients with multiple Comorbidities will help payments reflect these critically and chronically ill patients.
Who do I call if I have questions about THN?
Please call your practice liaison. If you do not know who your liaison is, please contact Sharon Pichany, Administrative Assistant, at Sharon.firstname.lastname@example.org