Questions & Answers

Overview

What is St. Elizabeth Provider Network?

St. Elizabeth Provider Network (SEPN) is a Clinically Integrated Physician Hospital Organization (CIPHO) committed to providing high quality, cost-effective health services to the patients it serves. SEPN is a network of St. Elizabeth and independent health care providers participating in joint contracting with payers for the purpose of aligning economic incentives and establishing common quality, care management and information technology infrastructure.

What is SEPN’s Mission Statement?

The Mission of St. Elizabeth Provider Network is to improve the health of the people we serve by focusing on the quality, service and cost of care provided through collaboration among independent community physicians, St. Elizabeth Healthcare and St. Elizabeth Physicians.

Background

Why was SEPN created?

As the reimbursement system increasingly rewards value over volume, the healthcare climate is emphasizing accountable care through population health management, care coordination and quality outcomes. SEPN will enable the provider community of Northern Kentucky to more effectively adapt to these changes.

What is Clinical Integration?

Clinical Integration is an active and ongoing process to evaluate and modify practice patterns by the program’s provider participants and create a high degree of interdependence and cooperation among the providers to ensure quality and control costs. Participation in an effective clinically integrated network will provide SEPN’s members the ability to contract collectively with health plans without violating antitrust laws.

What conditions must exist to qualify as clinically integrated?

A network of physicians willing to demonstrate a high degree of interdependence and cooperation, through a program of initiatives designed to ensure quality and control costs, which is supported by an Infrastructure allowing the physicians to evaluate and modify practice patterns.

What are some additional characteristics of effective clinically integrated networks?

• The development and implementation of detailed, evidence-based clinical practice guidelines.
• Limiting participation in the program to providers who are committed to accepting the limitations on independent decision-making which the guidelines entail.
• Measurement and evaluation of each participating provider’s compliance with the guidelines.
• Investment by all participating providers of time, energy and financial resources in the development and enforcement of the clinical guidelines, as well as the computer infrastructure needed to facilitate such integration.

Network Participation

Who is involved in the leadership of SEPN?

SEPN is governed by a board of directors comprised of equal representation from three groups: independent community physicians, St. Elizabeth Healthcare and St. Elizabeth Physicians and operates for the explicit purpose of overseeing the successful development, implementation and ongoing operations of SEPN. Employed and independent physicians lead and participate on committees that develop and maintain clinical protocols and govern the clinical and financial functions of the organization.

What are the advantages of participating in SEPN?

• Creates a network of clinically and financially aligned health care providers.
• Provides a vehicle for participating providers to effectively manage population health and coordinate care across the full continuum.
• Facilitates high-quality, cost-effective care delivery through promotion of evidence-based care standards and decision support tools, and reduction of unnecessary variation and utilization.
• Allows participating providers to effectively manage evolving patient care and payment models that reward value-based care.

What will I need to do in order to participate in SEPN?

Membership in SEPN is voluntary. In order to become a participating provider in SEPN, you will need to sign a Participating Provider Agreement (PPA) outlining the membership requirements.

What hospitals are participating in SEPN?

All St. Elizabeth Healthcare hospitals are participating in SEPN, including the Edgewood, Florence, Fort Thomas and Grant County facilities.

Do I have to participate in all SEPN contracts?

Participating providers are required to participate in all SEPN negotiated contracts with payors. However, SEPN is “Non-Exclusive” and does not prohibit providers from contracting directly and independently with third-party payors for base fees until SEPN has entered into a contract with that payor. Existing contracts outside of SEPN can remain in place. Provider billing practices will remain the same.

If I don’t participate in SEPN, will I lose my medical staff privileges?

Choosing not to participate in SEPN will not affect any provider’s medical staff privileges.

As a participating provider, am I required to refer within the network? Is there a risk to referring out-of-network?

Participating physicians are required to refer within the network in order to provide the highest quality and best outcomes for patients, as outlined in the PPA. The network is designed as a collaborative effort to manage quality through the coordinated and consistent use of evidence-based medicine across the full spectrum of care. Providers must refer patients to other participating providers except in cases of compliance with applicable law, medical necessity, third party payer restrictions or patient preference.

Is there a cost to join or maintain membership in SEPN?

There is no cost to join SEPN and no annual dues. SEPN may retain a portion of future earned surpluses prior to making a distribution to participating providers to help cover operating costs and expenses and establish reasonable reserves.