"Out of those 160, we ask the physicians to pick 90–110 measures from that menu," says Lerman, who also says that community-specific metrics can be added; but again, the process is entirely physician driven.
"We want all the physicians to feel that they have a voice," says Lerman.
Physicians who join a Dignity CI network are also expected to hold each other accountable for the quality metrics each network adopts. It's an opportunity to collaborate with other providers in a local community to develop a common set of quality and clinical standards. Dignity's theory is that patient care will improve, costs will go down, and physicians will have more job satisfaction.
Despite a built-in relationship with 9,000 physicians across three states, Dignity decided to recruit physicians for its CI network initiative in order to create closer partnerships with many of those physicians. The health system wasn't starting at ground zero, but this did represent new ground for the organization to hit the streets and convince physicians to join and, Lerman says, recruiting physicians hasn't been difficult.
"We had hoped that by July of 2012 we would have about 800 physicians throughout Dignity Health in the various CI networks, and we had about 2,700," he says. "The physician participation has been tremendous and the progress that we have made has exceeded our expectations." The number of physicians who've joined a Dignity CI network is now nearly 3,000.
The Arizona Care Network, an ACO based in metropolitan Phoenix, has 695 physicians, and the "vast majority" already has a relationship with Dignity or with its partner Abrazo Health Care, says William Ellert, MD, who helped develop the CI network as chief medical officer of St. Joseph's Medical Group, the employed physician group of Dignity's St. Joseph's Hospital and Medical Center located in Phoenix. Ellert is also chair of the Arizona Care Network's utilization review committee and chief medical officer for Tenet Healthcare's Arizona region.
Ellert says the Arizona Care Network has been able to attract physicians because of St. Joseph's long history in the area.
"St. Joseph's, which is one of the flagship hospitals of Dignity Health, has been in this community since the 1800s, and so partnering with the physicians was not a new thing for us," says Ellert. "We have a long history of trust with the physicians and so when Dignity Health says, 'This is the direction I believe we need to go in order to prepare for the future of healthcare,' a lot of the physicians believe them."
Another reason physician participation in the ACN is so large is because of the network's partnership with Abrazo Health Care, which is now part of Dallas-based Tenet Healthcare. Ellert, now chief medical officer for Tenet's Arizona region, says the addition of Abrazo's six hospitals, outpatient facilities, and medical group in the Phoenix area expand the ACN footprint throughout all of central Arizona, where two-thirds of the state's population lives. The geographic area is known as the Valley of the Sun, and Ellert says the partnership with Abrazo allows both systems to look at delivering care in a whole new way.
"As a network, we have geographic reach throughout the entire valley, and that was important for the community because you might work in the east valley and live in the west valley, so you have to have access to healthcare throughout the entire valley," he says.
The ACN gained status as a Medicare ACO in January 2013. It plans to commit 70% of the shared savings to physicians and 10% to hospitals. The remaining 20% supports the infrastructure of the ACN, with hospitals agreeing to give back 50% of their shared savings to support existing ACN infrastructure, if necessary.
Ellert says the ACN is going beyond the Medicare ACO model and is entering into a contract with Aetna that has a shared-savings component to it, as well as working with UnitedHealthcare. Giving independent physicians a voice in negotiating with payers is a big selling point of the ACN and the rest of Dignity's CI networks.
Even without years of data showing improvements in quality because the CI networks are still new, Ellert says early results from the first eight months of 2013 are promising. From January to August, Ellert says ACN saw a drop in inpatient admissions from 403 to 278 per 1,000 patients; for that same time period, there was also a reduction in emergency department visits from 419 to 353 per 1,000 patients. ACN is also credited with reducing hospital readmission rates, year over year, from August 2012 to August 2013 by 10%, from 16.1% to 14.5%. Ellert says the data indicates the CI network shows potential, and health plans are now approaching the network.
"Almost all the health plans are coming to us and saying they want to do this," he says. "Our goals are becoming more aligned. The trick is how do you jump from point A to point B, and that's where a lot of the difficult negotiations come in because we recognize that we're still building the infrastructure to be successful and the health plans, rightly, and the patients are saying, 'We want it now.' "
Both Ellert and Lerman are banking on the entrepreneurial spirit of the independent physicians to propel the network forward quickly. Ellert says the CI networks could be of particular help to primary care physicians.
"The thing that is either going to make this or break this is if we can somehow put aside some of our individual needs and biases and look at what the needs of a community are and the needs of our patients, and address those," says Ellert. "That's what PCPs have always done, but we're now being given some of the tools we need to make this successful."
Primary care's 20-minute milestone
Primary care physicians are often cited as the group of doctors under the most pressure. The American Medical Association, Association of American Medical Colleges, and more recently the National Center for Health Workforce Analysis, all project a shortage of primary care doctors by 2020.
Among the ideas to help fill the future gap in primary care practices include increasing the number of nurse practitioners and other medical staff, as well as expanding the scope of practice for nurses, putting them in more of a leadership role in primary healthcare; however, the idea isn't without criticism from the physician community.
"What's important to realize is that because of the differences in education and training, even doing the same service is different," says Reid Blackwelder, MD, president of the American Academy of Family Physicians, which represents 110,600 family physicians, family medicine residents, and medical students.