Frequently Asked Questions
It seems some of the activities related to membership in PCCN create contractual relationships between the organization and community physicians that may require legal review. What steps is Phoenix Children’s Hospital taking to make sure these activities and relationships put neither community physicians nor the hospital at legal risk of violating the Stark Law or other related regulations?
Q: What is Clinical Integration?
A: Clinical Integration (CI) is an FTC-recognized model of physician group contracting based upon development of a robust quality improvement program with real accountability among otherwise independent physicians. It integrates and rewards physician members around a common commitment to quality measures based on scientific evidence. Phoenix Children’s Care Network represents a partnership between and among community physicians, Phoenix Children’s Hospital and Phoenix Children’s Medical Group focused on the delivery of high-quality, coordinated, cost-effective pediatric
care. This new organization would position its participants for success in the value-based contracting environment, facilitate improved communication among participants, and utilize evidence-based clinical care guidelines developed by physicians. Participating providers and hospitals realize financial incentives for the delivery of high-quality, cost-effective care.
Q: What’s the difference between an Accountable Care Organization (ACO) and a Clinically Integrated Organization (CIO)?
A: It’s easy to get lost these days in what seems to be a ladle full of alphabet soup: ACA, ACO, CIO, MSO, PHO, and the list goes on. Let’s focus on two of those: ACO and CIO. According to the Centers for Medicare and Medicaid Services, an ACO is a group of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal is to ensure patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. A CIO (clinically integrated organization) is an FTC-recognized model of physician group (joint) contracting based upon development of a robust quality improvement program with real accountability among otherwise independent physicians. It integrates and rewards physician members around a common commitment to quality measures based on scientific evidence and cost improvement.
Q: Why a pediatric–focused Clinically Integrated Organization?
A: As you are well aware, the national health care landscape is undergoing significant change, driven by market dynamics and the Patient Protection and Affordable Care Act, which was signed into law in 2010.
A significant element of this change is the transition to a value-based reimbursement structure, where physicians and hospitals are paid based on quality outcomes rather than the current fee-for-service model. In addition, under the new law the insured population is likely to expand. Those considerations point to a need for provider-organized networks to coordinate delivery and management of care.
Additionally, local market conditions support the rationale for developing Phoenix Children’s Care Network, where participating providers and Phoenix Children’s Hospital could benefit from improved quality of care, resulting in optimized reimbursement and shared savings. Other organizations in the marketplace are developing adult-focused CIOs and ACOs. We believe that PCCN, with its laser focus exclusively on children and adolescents, best positions pediatric physicians to positively affect the quality and cost of pediatric health care while financially incentivizing providers for those efforts.
Q: Why would a community physician want to join PCCN?
A: We are committed to making the organization beneficial for both participating community physicians and the hospital. Health care reform is here – though we don’t know all the implications, we do know that a focus on providing quality care and controlling costs benefits all of us, and particularly, our patients. That focus, of course, is at the core of clinical integration. Additionally, marketplace trends right here in the Valley indicate a clinically integrated organization like PCCN is viable, and not solely from a contracting perspective. Physician alignment efforts through organizations like PCCN protect the independence of private practice physicians and position them well for ongoing business growth.
Q: How will PCCN be structured and governed?
A: The organizational development and management is guided by the Board of Managers.
Q: It seems some of the activities related to membership in PCCN create contractual relationships between the organization and community physicians that may require legal review. What steps is Phoenix Children’s Hospital taking to make sure these activities and relationships put neither community physicians nor the hospital at legal risk of violating the Stark Law or other related regulations?
A: Phoenix Children’s Hospital recognizes PCCN is a new model for physician-hospital relationships and, as such, gives rise to unique legal considerations. To ensure that all parties are fully aware of the legal implications, the Hospital, with guidance from the Board of Managers, selected a law firm specifically equipped to address the scope of issues and challenges that may arise through the process of organizing and structuring PCCN. Two documents – the organizational charter and participation agreement – define the scope of the relationship between community physicians and PCCN. Those documents have been carefully developed and vetted by legal experts and the Board of Managers to ensure all activities of and relationships between PCCN and its members are fully compliant with all applicable laws and regulations.
Q: Is there a cost to join?
A: There is no charge for community physicians to join PCCN. The infrastructure capital is being underwritten by Phoenix Children’s Hospital.
Q: Will community physicians be required to refer exclusively to Phoenix Children’s Hospital?
A: Referrals within PCCN would be encouraged and it may well be mutually beneficial to do so. It is consistent with the intent of the organization to provide the highest possible care to children; however, physicians will always retain the responsibility and right to direct their referrals in a manner that best serves the interest of the child when a specific specialty is not available from PCCN. The participation agreement addresses this arrangement in detail. Please review the agreement carefully for more information.
Q: Who would manage payer negotiations and what would reimbursements and quality-driven incentives look like for network members?
A: As we continue to explore the benefits of PCCN, the Board of Managers, with input from the Finance Committee, will help determine the focus of our negotiations with commercial payers. We will also look to physicians to help set quality standards that best serve our pediatric population, based on research and best practices.
Q: Would there be network-based business support for practices that align with PCCN?
A: Decisions on CIO benefits will be determined by the Board of Managers and participating physicians, so these details are still under discussion. However, planning efforts have identified various opportunities to offer beneficial services to members.
Q: What will happen if the Affordable Care Act (ACA) on Children’s Health Care is changed or repealed at a later date?
A: Regardless of political climate or federal action, Phoenix Children’s is committed to the principle goals of clinical integration: improving the quality and managing the cost of children’s health care in Arizona. These efforts are important to our physicians and the community as well. PCCN will take a proactive approach to crafting policies and procedures that best respond to the current legal environment. PCCN members will be made aware of any changes to terms of the participation or operational agreements and policies and procedures.
Q: If I have any questions about PCCN, with whom can I speak?
A: We understand PCCN represents an entirely new type of relationship between community doctors and Phoenix Children’s Hospital and you may have questions about our efforts. For your convenience, we’ve created a dedicated phone number and email address for you to contact a member of our PCCN team.
Phone: (602) 933-7226 (PCCN)
We welcome your questions and feedback. Please don’t hesitate to reach out.