Back to homepage
Login

FAQ

Organizational Overview

In late 2011, the Saint Alphonsus Health System (SAHS) leadership appointed a 19 physician ad hoc group from across the Treasure Valley to develop Saint Alphonsus Health System’s clinically integrated network. That group worked for five months to name the Saint Alphonsus Health Alliance, develop its governance, and create a Vision that was consistent with the SAHS Mission and Vision. The Saint Alphonsus Health Alliance went “live” in May of 2012 with the appointment of a Board.

The Alliance is the newly formed physician-led provider network of Saint Alphonsus Health System. The Saint Alphonsus Health Alliance will transform healthcare in our communities by collaborating with premier health care providers and engaging patients in their health choices while honoring Saint Alphonsus' faith-based Mission to heal body, mind and spirit. 

The Alliance was created to engage physicians to lead the transformation of Saint Alphonsus Health System to deliver high quality and affordable care. The Alliance will lead the development of a Health System organized for population health to accomplish the transformation from volume-based reimbursement to value-based. This transformation in care delivery and financing will require significant physician engagement and leadership to assure patient-centered care with the goals of Triple Aim:  improve the patient care experience, improve population health and reduce the per capita cost of care.

The Saint Alphonsus Health Alliance will transform healthcare by collaborating with premier health care providers and engaging patients in their health choices while honoring Saint Alphonsus’ faith-based Mission to heal body, mind and spirit. The Alliance will:

  • Improve the patient care experience
  • Improve the health of the communities we serve
  • Efficiently provide the highest quality, evidence-based care.
  • Be committed to innovation, value-based care, and ongoing performance improvement
The three main goals of the Alliance are to:
  • Transform care delivery by creating a physician-led Clinically Integrated Network with SAHS that is accountable for the full continuum of care.
  • Lead the market in high quality, cost efficient care through population health management that includes engaging patients in the ownership of their care.
  • Become the preferred partner for physicians in our communities through a culture of collaboration.

Besides addressing some of the requirements of Health Reform, the Alliance will address the need of payor and employers to stabilize premiums and decrease cost. In a collaborative and transparent effort between hospitals, physicians, payors (insurers/employers/government) and patients, the Alliance seeks to accomplish, at a minimum, the following:

  • Improve quality of care and patient outcomes
  • Maintain or improve the overall health of defined populations
  • Establish major diagnosis/disease state evidence based clinical guidelines that are cost effective and yield more reliable quality and results
  • Develop a Alliance-wide system to communicate and evaluate performance within clinical guidelines.
  • Develop a comprehensive patient wellness program for preventative care
  • Develop a communication system that allows for transparent communication between all network providers regarding coordination and management of the individual patient overall health
  • Explore alternate reimbursement methodologies that are more based in outcomes than only fee-for-service practice.
  • Maintain or reduce healthcare costs
  • Develop mutually acceptable shared financial goals and risk/incentive systems to incentivize great outcomes.

Physicians and hospitals will need to work together in a collaborative fashion to improve the health of the population as payment for care changes from volume based to value based incentives. The Alliance will need physicians to get involved in that transformation to improve the quality and the coordination of care that will increase efficiency and cost effectiveness. Through involvement in the Alliance you have the opportunity to influence collaboratively the selection of the quality initiatives and the measures by which success will be determined.

In the future, the Alliance will negotiate contracts on your behalf that have quality and utilization incentive goals. If you achieve the goals, you will receive incentive payments. In the future, the Alliance may also accept risk, either sharing in the savings if costs are reduced, or sharing in incentives from improvements in quality and efficiency with bundled payment and capitated contracts.

Fee schedules will be determined by recommendations from the Contracting Committee, with Board approval.

Numerous opportunities will arise for interested physicians to serve on Alliance Committees and task forces of the Alliance. Please contact any of the Board members listed to discuss your interests.

Clinical Integration

A CIN is a group of hospitals and providers who collaborate and contract together to improve quality and control costs, i.e., achieve value. The Legal definition of acceptable Clinical Integration provided by the Federal Trade Commission (FTC) and U.S. Department of Justice, 1996, states: “Clinical Integration is an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. This program may include:

  • establishing mechanisms to monitor and control utilization of health care services that are designed to control costs and assure quality of care;
  • selectively choosing network physicians who are likely to further these efficiency objectives;
  • the significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.”

In a collaborative and transparent effort between hospitals, physicians, payors (insurers/employers/government) and patients, the CIN seeks to accomplish, the Triple Aim:

  • Improve the patient experience, not just patient satisfaction scores but access to healthcare through patient portals and access to non-physician members of the healthcare team who can manage many day-to-day matters of chronic disease management and wellness.
  • Improve the health of the network’s patient population using evidence based chronic disease management, evidence based referral, and wellness programs.
  • Reduce the per capita cost of healthcare in the covered population by using wellness programs, evidence based referral, screenings, and evidence based chronic disease management protocols.

Some of the mechanisms that can be used to achieve the above aims include:

  • Establish major diagnosis/disease state evidence based clinical guidelines that are cost effective without sacrificing quality
  • Develop a system to communicate clinical guidelines to the entire network and evaluate and gain compliance with the guidelines
  • Develop a comprehensive patient wellness program
  • Develop a communication system which allows for easy and open communication between all network providers regarding coordination and management of the individual patient overall health
  • Explore alternate reimbursement methodologies that are more outcome based versus fee-for-service based
  • Develop mutually acceptable shared financial goals and risk/incentive systems to reward compliant behavior

Several health systems formed networks several years ago to manage risk contracting and many of those have evolved into successful CINs. One of the more well known is the Advocate Physician Partners (APP), a network of physicians associated with the numerous Advocate Health hospitals in the Chicago area. The network has approximately 3,800 physicians now (900 are employed and the rest are independent). Each year they produce a report to the community showing how the network, by the use of quality improvement processes and incentives to the physicians, has improved the health of their patient population with results that are better than other populations in both Chicago and Illinois. The report can be found on the APP website (http://www.advocatehealth.com/2012valuereport). Dozens of others are in various stages of development and implementation, and we will continue to provide you opportunities to learn from them. Another mature CIN program is the Geisinger Health System.

CINs that were not physician led have not been as successful as physician led and accountable networks, a major design principle for the Alliance. Physicians must lead these improvements in clinical care in partnership with hospitals and other health care entities and providers that will be part of the overall solution. Evidence shows that currently only about 55% of patients receive all of the expected care for a given chronic conditions. Physicians, hospitals, and other providers must work together to improve the health of our patients.

A CIN is a group of hospital and providers who collaborate and contract together to improve quality and control costs, i.e., achieve value. While the Advantage Care Network (ACN) includes hospitals and providers, the parties are independent and their contractual obligation doesn’t include the improvement of quality and control costs unlike the Alliance. A CIN aligns the incentives and goals of providers and hospitals.

If the following milestones are achieved, the System will have positioned itself for success in the healthcare reform era:

  • Enter a participation agreement with 800-1000 providers where the provider(s) agree to comply with clinical guidelines and be clinically integrated with the Alliance
  • Implement systems that will enable the Alliance to measure and report to all constituencies financial, quality and utilization performance in a contemporaneous fashion.
  • Establish major diagnosis/disease state evidence based clinical guidelines that are cost effective without sacrificing quality
  • Develop mutually acceptable shared financial goals and risk/incentive systems to reward it members for great outcomes
  • Demonstrate with data that patients in the Alliance have better patient care experiences, are healthier, and pay less for their care
  • Pursue value based reimbursement contracts with employers and health insurance providers

Over time, all Alliance members will be part of a deployment of a web-based disease management registry that will give you access to data about your patient population. You will be asked to use evidence based protocols endorsed by your colleagues within the Alliance for certain common diseases when possible and review your patients’ data as part of your practice pattern to ensure that your patients are receiving all of the care needed for their conditions. SAHS and the Alliance believe that healthcare in the future will require much more teamwork and interdependent activities.

At present, your office is not required to have an EHR. However, your office must have an electronic claims submission or billing system so information from that system and other electronic billing warehouses can be obtained. Your office would be expected to participate in the patient registry system that is the backbone of the Alliance’s quality monitoring system.

Alliance members will be required to contribute some patient information to the patient registry. Most of the data, such as diagnoses and laboratory information will come from other electronic systems including claims systems.

Initially, the Alliance will not enter into risk contracts, but will evolve with incentive contracts as the informatics infrastructure and expertise develops within the Alliance. The early pay for performance contracts will have only potential for gains and pay for performance shared savings arrangements, and these could be ready in late 2012. Eventually, the Alliance will enter into well considered full risk contracts when systems are in place to manage risk. To engage contracted providers in any form of risk or shared savings, providers will need to be committed. One commitment mechanism is a “withhold” arrangement tied to fee for service reimbursement. A portion of the withhold could be distributed to Alliance members based on their performance. Again, the Alliance does not anticipate this type of contracting until systems are in place to manage risk.

At present, the Alliance will not seek to become an Accountable Care Organization (ACO) that focuses on Medicare FFS beneficiaries. The Alliance’s immediate focus will be insurers and employers in the Treasure Valley. This focus does not preclude the Alliance’s involvement in Medicare including Medicare Advantage Programs, and of course, Alliance membership does not preclude its members’ involvement in federal programs. In the future, the Alliance portfolio of contracts may include a Medicare ACO arrangement.

Medicaid contracts will be reviewed on a case by case basis but will not be a targeted payor.

Eventually, the Alliance will seek contracts with the value proposition that could include bundled payments, episodic payments, or capitation. However, the initial focus of the Alliance’s contracting will be contracts that have only upside potential to its members. Later as the Alliance matures in its informatics and quality capability, more complex incentive contracts would be considered based on the needs of payer and employers.

Membership and Participation

Alliance membership includes a number of benefits including:

  • access to a number of commercial contracts;
  • participation in a network of physicians that seeks to improve the health of its community in measurable terms by being part of the solution to spiraling healthcare costs;
  • obtaining the tools to measure your practice’s patient care performance relative to your peers;
  • rewarded with additional reimbursement for practices that achieve and demonstrate the value, not only the volume, of care provided.

The physician-led Alliance Board of Trustees has the responsibility to establish specific criteria for participating members. At a minimum, participating members must satisfy certain standard credentialing requirements including without limitation NCQA requirements and standards. Participating members must also have a desire to clinically integrate his or her practice with Saint Alphonsus Health System hospitals and facilities and other providers participating in the Alliance. This clinical integration is necessary to satisfy the ultimate goal and objective of the Alliance, which is to provide outstanding medical care to our communities at the lowest possible cost.

The distinction between the Alliance and existing payor contracting networks with which you may be familiar is two-fold. First, the Alliance is physician led and governed. Not all participating providers will desire or be expected to serve on the Board of Trustees or in various committees. However, the providers that do participate will be able to ensure the network operates in the best interests of all providers and patients. Second, as a clinically integrated network, providers will have access to patient information that will help improve the quality of a patient’s care across all specialties and facilities. In the future, certain payor contracts entered into by the Alliance may contain provisions that require patients to be seen by a certain panel of physicians and this could potentially change your referral pattern for those patients. The Alliance panel will share the same values as the referring physician, so they will be aligned by the same incentives around quality and costs. Over time, the benefits of referring to physicians with whom you are clinically integrated will be obvious and in the best interest of patient care.

Around the country, clinical integration network funding typically includes options such as withhold of fee-for-service payments, withhold of a portion of the incentive or shared saving payments, or fees and dues. Funding issues will continue to be discussed by the Alliance Board with input from Alliance members and the Committees.  At the present time, Saint Alphonsus Health System provides all funds necessary to operate the Alliance.  These costs are offset by payments from payers that are based on the overall performance of the network.

Qualifications to enter the Alliance and maintain participation are:

  • Board Certified, or become Board Certified within a specified time in practice depending on you specialty and Alliance credentialing criteria. The Alliance Board will consider nonboarded physicians on a case by case basis.
  • Be credentialed by the Alliance.
  • Comply with Alliance policy and procedures that will be forthcoming.
  • As the Alliance matures, requirements to meet minimum performance on Alliance endorsed quality and utilization metrics may be used in credentialing and membership decisions.

If you do not have any hospital medical staff membership, you do not need to have membership in an Alliance hospital. However, if you have medical staff membership at a non-Alliance hospital, you must have membership on an Alliance hospital’s medical staff.

Yes, providers are allowed to join other networks.

In the near term, the Alliance will function as a messenger model physician hospital organization. With the acquisition of contracts with elements of clinical integration, it will evolve into a fully integrated network and as such will contract on behalf of all member providers. In addition to realizing the goals of clinical integration, this evolution will allow the Alliance to react to contract opportunities much quicker and efficiently. The Alliance Board has yet to develop policies concerning opting out, so at present, you can opt out per the Advantage Care Network rules.