Prisma Health Upstate Network is a clinically-integrated network of healthcare providers who share a common goal of improving health outcomes, reducing healthcare costs, and enhancing the patient experience.

The network utilizes a collaborative model that empowers providers to create a healthcare delivery system that can operate in a value-driven environment. The model includes a Board of Managers who provide leadership and oversight for the network, as well as committees that focus on improving and standardizing care. The committees are made up of network providers and organizational administrative staff who represent communities served by the network.

By putting management and decision-making in the hands of providers, Prisma Health Upstate Network can ensure that clinical quality priorities remain at the forefront of care. Additionally, the network’s structure allows non-hospital employed providers to remain independent while participating in a large provider network. The network’s large geographic footprint also enhances its ability to manage populations for government payers and large businesses, whose patients or employees reside in multiple communities, resulting in greater access to care.

Prisma Health Upstate Network is supported by resources designed to help providers improve health outcomes, reduce healthcare costs, and enhance the patient experience. The network’s primary resources include the Care Coordination Institute (CCI) and Network Administration Services (NAS). The CCI’s role is to provide training, education, and other resources to improve outcomes, while NAS’s role is to engage payers and insurers in innovative payment models, while monitoring and measuring cost and quality.

No. Prisma Health Upstate Network will not purchase or run your practice or hospital. The goal is to bring physicians, hospitals, and other healthcare providers together to improve health outcomes, reduce healthcare costs, and enhance the patient experience.

First, because participation in the network is completely voluntary, providers need to sign a participation agreement to be included in the network. Second, participating providers will be required to collaborate with other network participants in the development and adoption of clinical initiatives that will enhance the quality, service and cost-effectiveness of patient care. Lastly, providers will need to hold themselves and each other accountable for compliance with the initiatives of the network. This includes clinical care models and quality and process monitoring, as well as disciplinary and remediation efforts (should providers not meet the standards of quality patient care set forth by the Prisma Health Upstate Network board and committees).

Prisma Health Upstate Network eligibility criteria includes but is not limited to:

• License to practice in South Carolina
• Board certification (or demonstrate clinical quality excellence)
• Use existing electronic medical record (EMR) or develop short-term plan to acquire EMR within one year
• Must be eligible to participate in federal healthcare programs, including, without limitation, Medicare and Medicaid
• Serve as member of the medical staff of one of the MyHFN hospitals (e.g., active, courtesy, or collaborative/referring primary care physician)
• Bill payers electronically for both inpatient and outpatient activities
• Participate in care improvement initiatives developed by the network

The agreement is with the practice, but insurers and other payers may also require that it be signed by individual physicians. The practice will internally determine the best way for its members to participate in network contracts, fulfill associated committee and leadership opportunities, and distribute performance bonuses. A practice must sign a participation agreement to be included in the network.

Prisma Health Upstate Network will be the exclusive network with which a primary care provider may contract. It should be noted that certain payer arrangements, such as shared savings programs, require the tax ID used for participation and billing to be linked to only one network. For example, the tax ID used by primary care providers for Medicare billing can only participate in one Medicare Shared Savings Program (ACOs), and similar restrictions may apply to commercial health plan ACOs or other value-based payment models. Participating in MyHFN does not restrict the provider’s ability to refer a patient to another physician, hospital or provider that is best for that patient’s care. Specialists may participate in more than one network.

The expectation is that providers use an existing EMR or develop a short-term plan to obtain an EMR within one year. While a common EMR across all network participants can certainly accelerate and strengthen Prisma Health Upstate Network, most successful network models nationwide do not depend on a single EMR for data on provider performance. Prisma Health Upstate Network utilizes claims data, existing hospital data, registries and chart audits to evaluate provider performance. Therefore, it is not expected that all providers in the network have the same EMR; however, they will be required to share data.

No, while Prisma Health Upstate Network will seek to create opportunities that may not be available through your individual or group contracts, it will not replace all payer contracting. Prisma Health Upstate Network will seek to create select shared savings and value-based payment opportunities with a limited number of payers, which will not replace your current contracting arrangements.

Yes, providers will participate in all contracts. Successful networks have found that their ability to drive quality and efficiency improvements is greatly enhanced if members participate in all contracts. Initially, these contracts will only constitute a small percentage of a provider’s overall patient panel.

It is anticipated that a portion of the contracted payment related to achieving quality and performance metrics will be paid to and administered collectively by Prisma Health Upstate Network. Therefore, a portion of the contracted payment may be dependent on the performance of the network as a whole, as well as your own performance. Over time we anticipate that capitation and other risk type arrangements that utilize the same quality improvement and medical management techniques may be entered into by Prisma Health Upstate Network.

No. Prisma Health Upstate Network allows a network of otherwise independent physicians, hospitals, and providers to approach payers as a group to contract for new approaches to care delivery, such as shared savings programs. The success of the network in obtaining such arrangements with payers will depend on the payer’s willingness to contract for improved quality through financial incentives, and the provider’s ability to achieve improved quality and efficiency as consistent with the goals of Prisma Health Upstate Network.

The agreement is not negotiable because it needs to be consistent across all hospitals, practices, and providers. When the enrollment period ends, the Prisma Health Upstate Network Board of Managers will review the agreement and determine if changes are needed based on feedback received from providers. As stated in the agreement, a provider can terminate participation after reviewing any proposed changes to the agreement. If you have questions about the agreement, please contact Kim Roberts at kroberts@myhfn.org.