Building a National Network of Cardiac Providers Aligned Around Predictable Performance

The Cleveland Clinic Cardiovascular Specialty Network was established earlier this year and is now actively adding member provider organizations across the country. This is the country’s first national-scale network of affiliated cardiovascular care providers for the purpose of contracting with employers and other payers.

Predictable quality at a predictable price

“We’re assembling a group of like-minded provider organizations aligned around quality-driven, high-performance cardiovascular care,” explains Joseph Cacchione, MD, Chair of Operations and Strategy for Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute. “The aim is to present a network offering to provide predictable quality at a predictable price to large employers, health exchanges and physician-owned accountable care organizations.”

The Cardiovascular Specialty Network is able to ensure predictable quality thanks to an intensive assessment process Cleveland Clinic uses to evaluate potential network members for clinical and operational quality, data integrity and cultural alignment. That process has emerged from a robust program of affiliations, alliances and consulting relationships Cleveland Clinic has forged around cardiovascular care dating back to the late 1990s. These relationships — from consulting arrangements to extensive clinical and research alliances — are outlined below:

• Consulting services — Focused engagements in which Cleveland Clinic Heart & Vascular Institute staff provide advice and insight to another hospital or health system for defined services. These services run the gamut from quality assurance reviews to physician recruitment to data auditing to clinical protocol reviews. These relationships are initiated at the request of the outside organizations, which range from small community hospitals to large academic medical centers. The Heart & Vascular Institute is typically engaged in 10 or more consulting relationships at a given time.
• Affiliations and alliances — Deeper relationships in which Cleveland Clinic establishes branding with another hospital or health system after Heart & Vascular Institute staff conduct an intense six- to 12-month assessment of the organization’s cardiovascular program for quality, outcomes, data integrity and culture. Organizations that meet required criteria are designated Heart & Vascular Institute affiliates and have access to Cleveland Clinic intellectual property, protocols, care paths and clinical trials; enhanced consultation access to Heart & Vascular Institute physicians and administrative experts; and enhanced connectivity for sharing of imaging studies. Affiliations with selected larger provider organizations are designated alliances and involve more extensive clinical and research collaborations.
• Cardiovascular Specialty Network membership — A chance for provider organizations to join Cleveland Clinic in contracting with large employers looking for a dispersed network of high-quality cardiovascular providers for their employees around the nation. The network allows Cleveland Clinic to triage cases across the nation to the network member most appropriate for them — either to a nearly affiliate for more straightforward procedures (e.g., CABG or mitral valve repair) or to Cleveland Clinic for highly complex surgeries like reoperative procedures. Cleveland Clinic initiates requests for network membership, and network members must be affiliates or alliance partners, though not all affiliates are network members (some do not yet meet the network’s stricter quality requirements).

Why this approach now?

The new network is a way to better leverage Cleveland Clinic’s direct-to-employer contracts to provide cardiovascular care to large national employers and private health insurance exchanges. Such contracts currently cover a couple million lives, and ongoing discussions with Fortune 500 companies aim to increase that count.

“Employers are asking for more local options,” explains Daniel Towarnicke, the Heart & Vascular Institute’s Director of Outreach Programs. “The idea is to work with hospitals throughout the country that demonstrate the best performance and patient experience so that our contracted employers can encourage employees to use nearby network providers when possible and appropriate.”

Benefits all around

“Healthcare is often regional,” adds Dr. Cacchione, who notes that a national network covering all major regions yields benefits for all stakeholders:

• Cleveland Clinic benefits through an enhanced and extended national presence and through relationships that may give patients enhanced access to Cleveland Clinic surgeons.
• Network affiliate providers benefit from their inclusion in the employer contracts and the halo effect of being affiliated with the nation ’s top-ranked heart program. They also gain from the sharing of data and best practices, ongoing quality improvement initiatives and supply chain savings inherent in the network.
• Employers get predictable pricing along with the assurance that their employees receive reliably high-quality care from vetted best-in-class cardiovascular providers.
• Patients covered under the network gain the ability to visit a more local provider while still having access to Cleveland Clinic for their most complex needs — all under a benefit structure designed to minimize their out-of-pocket costs.

Scrupulous quality standards

Many of the above benefits hinge on the Cardiovascular Specialty Network’s promise of strict quality standards. Those standards cover diverse aspects of clinical and operational practice and are closely guarded by Heart & Vascular staff at every turn.

In addition to hard measures like monthly outcomes data supplied by the American College of Cardiology and the Society of Thoracic Surgeons, the intensive assessment of potential affiliates and network members includes reviews of patient experience measures, quality processes, operational and administrative procedures, and data integrity.

“Data integrity is the first thing we focus on,” says Towarnicke, since it’s essential to reliably documenting the other measures and has become central to the drive toward safer and more efficient care. “We have a team that does site visits to assess data infrastructure, data auditing and similar issues.”

Site visits by top docs

They’re not the only ones who do site visits. For more than six years the Heart & Vascular Institute has been sending a diverse team of clinical and administrative experts — physicians, nurses, data analysts, continuous improvement specialists, project managers and others — to do site visits for potential affiliates and consulting clients. Each section of the Heart & Vascular Institute has one or two go-to physicians who regularly do such visits and provide ongoing consulting to affiliate hospitals.

Such involvement by physician leaders turns a lot of heads. “Cleveland Clinic is a physician group, so this is a physician run network and affiliate program,” says Dr. Cacchione. “We pay our cardiology and cardiothoracic surgery departments for a portion of their physicians’ time so they can do site visits to evaluate for quality and operations. We send some of our highest-performing physicians — national experts like Dr. Stephen Ellis and Dr. Bruce Lindsay — out to do program evaluations. This network is based on quality, and physicians understand clinical quality better than anybody.”

Continuous improvement at the cultural core

Dr. Cacchione’s team recognizes that quality can be used as both a stick and a carrot. It will terminate a relationship with an affiliate hospital that has poor outcomes — and has done so once thus far. But it likewise brings an ethic of continuous improvement to its relationship with each of its various partners. “Our range of consulting and affiliate relationships is a continuum,” explains Towarnicke. “We will work with consulting clients if they aspire to qualify for affiliate status. For affiliates that don’t qualify for Cardiovascular Specialty Network membership, we consult and work with them so that they might ultimately meet that quality threshold. A commitment to continuous improvement is important.”

Dr. Cacchione says that commitment is the key to the “cultural fit” he looks for in potential network members. He shares the story of one hospital that said they couldn’t fix a bad metric they had. “They asked me, ‘You won’t let us into the network just because of that one metric?’ I told them it wasn’t so much the bad metric as the fact that they said they can’t fix it and don’t seem to want to. None of us is perfect, but we all need that drive to be better every day. That’s the culture we’re looking for.”