What is a PHO?
A PHO is a legal entity formed by hospitals and physicians that allow them to come together to pursue common interests in a collaborative manner. For example, a PHO can act as a single unit to develop comprehensive health services arrangements with managed care companies and other payers. A PHO is often the first step on the path to further integration of the provider community and can serve as the governance and provider network for a community Accountable Care Organization. In addition, a PHO can sponsor education, look for common services to provide its membership, and other projects that become more relevant and cost effective when coordinated as a larger group.
Why will managed care companies and other payers want to contract with the PHO?
To be attractive to patients, employers and managed care payers, the PHO must be able to demonstrate value, higher quality at lower costs. The PHO serves as a central resource for contracting and for providing information in an administrative manner, which provides the basis for establishing relationships with various payers and demonstrating value to working with the PHO. The PHO also offers active care coordination, exchange of clinical information and involvement of physicians in developing standards of care and monitoring utilization.
What benefits does a PHO offer to individual physicians and their practices?
Because a PHO offers a comprehensive network of providers that are collaborating in managing patient care, and focused on quality improvement, the PHO can often develop more advantageous agreements with Managed Care plans than individual providers. The PHO‘s large provider network of physicians and hospitals offers health plans and other payers a significant partner to work with on innovative patient care initiatives. WCHN PHO provides significantly greater value to the health plans than by working separately with small individual physician practices. As a result of the value provided by the PHO, payers are willing to offer additional performance incentives for integrated groups of providers who are committed to collaborate to control costs, enhance quality, and improve patient satisfaction. In addition to the opportunity to participate in the PHO’s managed care agreements, the PHO offers a growing menu of Practice Management Support Offerings, including various administrative and technology solutions that may be beyond the resources available to individual physicians.
What is the purpose of the PHO?
- To arrange for the provision of health care services to people residing or employed in our communities, provided, that the PHO does not itself practice medicine
- To implement protocols and programs for health care providers that promote the quality and efficiency in the delivery of health care
- To provide contracting, management, purchasing, administrative and other services to medical and dental practitioners
What functions will the PHO provide?
The PHO works with its members to establish priorities, but the overall functions will include the following:
- Maintain and administer a comprehensive provider network
- Provide an ongoing Managed Care strategy
- Create/implement a Clinical Integration strategy
- Provide general support to community practice managers
- Provide a general communications function for the physician community
- Implement community and employer outreach activities
- Develop a portfolio of optional Practice Management Services offerings for a reasonable fee
- Serve as the vehicle for all system Accountable Care Organization (ACO) contracting
What management services does the PHO expect to provide Member Providers?
One major emphasis of the PHO is on technology and information exchange. The PHO has identified solutions for member providers regarding Electronic Medical Records, Health Information Exchange and population health management software. Other services the PHO currently offers its membership include the following:
- An Electronic Medical Record (EMR) system offering of a top rated EMR system at very attractive rates
- Participation in WCHN’s HealthLink Health Information Exchange (HIE) program
- Guidance in the transition to the Patient Centered Medical Home (PCMH) model of care
- Opportunity to participate in a national Group Purchasing Program for physicians providing significant cost reductions in a wide range of goods and services.
- Educational and networking programs for physicians and their practice management staff, including forums on ICD-10 Coding
What is the governance of the PHO?
Western Connecticut Health System PHO is governed by two classes of Members – the Hospital Member and the Physician Members. The Hospital Member shall be Western Connecticut Health Network and the Physician Members shall be those physicians who are participating members of the PHO.
The Board of Directors consists of fifteen (15) members, including five Hospital Directors appointed by WHCN and ten Physician Directors elected by the Physician Members. The Physician Directors includes five primary care physicians and five specialist physicians.
How are decisions made by the PHO Board?
The Directors of each class of members have one vote for all actions/decisions of the Board that require votes. The vote of each class of members will be determined by the vote of a majority of the Directors of the respective class of members present.
Who is eligible to join the PHO as a participating Provider?
The PHO Membership is open to all physicians, dentists or podiatrists who maintain active membership and clinical privileges on the Medical Staffs of Danbury Hospital, New Milford Hospital, or Norwalk Hospital.
What changes do individual practices have to make to become part of the PHO?
Under the PHO, physicians still own/manage their own individual practices and will bill and collect for services provided. The only requirement is that each physician of the practice has to sign a PHO Provider Agreement to be a PHO Member and if they agree to participate under any of the PHO’s Managed Care contracts, they must comply with the applicable policies, procedures and systems of the PHO and the respective managed care entity.
Do all physicians of a practice have to participate?
Do participating providers have to accept all contracts entered into by the PHO?
Not at this time.
Can Allied Professional Staff (Mid Level) Providers of PHO affiliated practices participate under the PHO payer agreements?
That depends on the payers’ respective policies and fortunately, most payers do allow PHO affiliated Mid Levels to participate under the PHO agreements.
What is the term and termination provision of the Provider Master Agreement?
The initial term shall be from the Effective Date until December 31 of the then-current year. Thereafter, the Agreement automatically renews for subsequent one (1) year terms unless notice of non-renewal is given not less than ninety (90) days prior to the end of the term or unless this Agreement is terminated pursuant to the termination with Cause or without cause provisions, which may result in an earlier termination period.