Clinical Integration and CPGs
The development of Clinical Practice Guidelines (CPGs) is just the next step in expanding our Clinical Integration requirements. In order to collectively contract for reimbursement rates and not be in violation of the Federal Trade Commission’s Anti-Trust regulations, Clinical Integration programs must be implemented that demonstrate they “...improve the quality and effectiveness of health care services that are delivered to patients.”[1] In FTC reviewed organizations, significant components of successful Clinical Integration included:
- Practice Standards and Goals for Physician Members
- Utilization and Quality Measured Against Protocols
- Evidence-Based Practice Guidelines or Protocols and Quality Benchmarks
- Monitoring of Individual and Aggregate Performance in Applying the Guidelines and Achieving Network Benchmarks[2]
To paraphrase, as you exercise your right to negotiate or contract collectively, you are responsible for engaging in Clinical Integration initiatives aimed at improving ‘ the quality and the effectiveness of healthcare services...’Although the 2011 CPGs apply to a larger population of Saint Francis HealthCare Partners, the measurement of utilization and quality is not new to SFHCP members. As you know, currently over 50% of all recognized physicians and practices listed on NCQA’s website are SFHCP members.[3] We provide physicians and practices with assistance in submitting data to NCQA for recognition in Diabetes, Heart and Stroke, and the Patient Centered Medical Home programs. In addition, we continue to provide practices with satisfaction surveys and measure patient feedback. Numerous educational presentations—both formal and informal, in groups or at individual offices—offer providers and staff various learning opportunities. Finally, our annual conference is a nationally recognized venue for providing timely information to healthcare providers on relevant healthcare issues. Efficiency and effectiveness at the practice level is promoted by SFHCP’s ‘One patient, one chart’ approach to managing patients’ clinical and administrative information. Finally, utilization review of resources has been in place at SFHCP for over 10 years. A stated, the new CPG process is just an expansion of these Clinical Integration initiatives.
Each CPG is developed from nationally recognized sources on evidenced-based practice and/or recommendations from relevant specialty organizations. The physician sub-committee of the Quality and Care Coordination committee develops the guidelines. These proposed guidelines are presented to the joint membership of the Quality and Care Coordination committee for approval. Once approved, each CPG is submitted to SFHCP Board of Directors for review and final acceptance. Only then is the CPG valid as a metric. It is anticipated that new CPGs will be added annually to ensure that all physicians have the opportunity to highlight the positive results of their care and interventions.
To learn more about Clinical Integration, please contact Rose Stamilio.
To see the list of Clinical Practice Guidelines (CPGs)