Clinically Integrated Networks
by Dr. Jon Hart
A clinically integrated network (CIN – sometimes pronounced “sin,” which is why I prefer to spell out the letters, “C-I-N”) is a group of healthcare providers that work together to actively assess and modify services to deliver efficient and affordable coordinated care to specific groups of patients. They share pertinent information and data, creating a high degree of interdependence and cooperation among the clinically integrated providers to control costs and ensure quality, usually via an electronic platform. Additionally, a CIN can negotiate on physicians’ behalf with payers and often can get better reimbursement rates.
That last bit sounds like doctors and/or health systems colluding to form a Trust or Monopoly or giving Kickbacks, doesn’t it?
For this reason, since a stated goal of the Affordable Care Act was better coordination of care to reduce duplicative testing, facilitation of consultations among various specialists, and helping patients get the right treatments faster, the Federal Trade Commission (FTC) legally defined a CIN in 2009 in preparation for the ACA’s passage. To accomplish that, provisions needed to be made for non-affiliated physicians and health systems to work more closely without fear of Anti-kickback or Starke Law violations.
Fortunately, significant regulatory reform has occurred over the last several years to recognize the movement away from fee-for-service to value-based arrangements, and referrals within a properly structured CIN can provide significant value to the overall health of the patients in the CIN.
Core Components
It is important to realize that a CIN is a legal structure, not a payment model. As we’ll see later, multiple payment models can live under this one CIN structure, but the components focus on legally integrating rather than payment.
The FTC defines a qualified clinically integrated arrangement as a joint contracting program that meets the following guidelines:
Nonexclusive: The program should allow for independent contracting, especially if payors and the network can't agree on terms
Price setting: Price setting should only be for services that are part of the program
Physician risk: All physician participants must share substantial financial risk through the arrangement
No unnecessary exchange of pricing information among physicians and hospitals
The arrangement must not facilitate the refusal of, or restrict physicians in contracting with payers.
Demonstrating true clinical integration requires that the participating physicians commit to developing and following rigorous quality standards, acquire IT resources that allow advanced data analysis, and enforce sanctions against physicians who are not meeting the network’s requirements.
Put into narrative form by FTC Commissioner Pamela Jones Harbour in 2009:
“The essence of clinical integration is the creation of interdependence among health care providers. Put simply, each provider must have a vested interest in the performance of the other providers, such that their financial and other incentives are closely aligned to meet common objectives. In addition, physicians are most likely to conform their behavior to network goals when their performance is judged by objective standards, in comparison to their peers.
“An effective organizational structure likely will facilitate coordination of care – for example, across different primary and specialty practice areas, or between different locations where care may be provided to a given patient. An effective organization also is likely to be structured in a way that encourages adherence to common quality and outcome objectives. Ongoing peer review, data driven utilization management and outcome measurement, and other mechanisms are likely to ensure that high-quality care is being delivered in the most cost-effective manner.”
Ms. Harbour went on to summarize by saying, “A clinical integration program [must] create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality, [and is] likely to yield significant efficiencies.”
These are the standards by which a CIN is judged and held immune to anti-trust regulations.
In other words when a joint venture or health care network is sufficiently integrated, by either sharing substantial financial risk and/or substantial clinical integration, they can legally, jointly contract with commercial payers. In contrast, integration that is designed solely to leverage size to negotiate higher fee-for-service reimbursement raises serious federal and state antitrust concerns.
To help make sure all the right “t’s” are crossed and “I’s” are dotted, an organization can go through URAC Accreditation as a CIN. This can help alleviate some of the anti-trust angst.
Here’s the good news: CINs work. Recent trends indicate CINs make a significant impact in enhancing the overall quality and cost of patient care, which payment-for-quality measures are designed to achieve when they are carefully designed and managed.
Types
There are three basic types of CINs, though these acronyms can also exist outside the legal definition of a CIN:
Joint Venture Physician-Hospital Organizations (PHOs) – a CIN that is comprised of physician and hospital partners. These CINs can have one or more hospitals/health systems (usually only one system, though), physicians employed by a sponsoring health system, and multiple non-affiliated private practices or groups all in the same CIN.
Health System Subsidiaries – a CIN that is operated as part of an Integrated Delivery Network (IDN). These usually are made up of only a single health system and physicians, facilities (like ambulatory Surgery Centers or Skilled Nursing Facilities), and providers (like Home Health or PT/OT/ST) employed or owned by the parent company.
Independent Practice Associations (IPA) – a CIN comprised of physician partners from multiple groups and practices (of course, this can also mean a nice, hoppy beer).
Conventionally, a practice, group, or organization maintains its own Tax ID Number (TIN) when joining a CIN. This structure is not about a hospital or corporation buying practices. Physicians stay in their own practices but share commitments and best practices with the group.
Side note: This is why I wish the industry had adopted a “hard C” (K) sound for the common abbreviation pronunciation rather than the “soft C” (S). We would then refer to this as a “Kin,” which fits more with the structure of a CIN. It’s made up of folks with whom you share something in common but can have different last names and live in different houses. You don’t necessarily need to even like each other or get along. At the end of the day, though, you do your part and you’ve got the back of the others with whom you share the relationship.
As noted in the IDN model, there are CINs comprised completely of employed physicians within a health system. A “refined” model of this CIN type exists with companies like Privia which are not health systems, per se. They call themselves a CIN, but they operate under a single TIN, much like an IDN would.
Here’s the cool part about CINs: they can manage any and all sorts of patient populations – Medicare FFS ACO, Medicare Advantage, Medicaid Managed Care, Commercial ACO, direct to employer care for a self-insured company, and more. A CIN may negotiate with a payor to manage the health care of an identified population and receive upside and downside financial risk associated with the same. It may contract to care for one or more employers’ self-insured employee populations. It can even identify a community need to address a particular underserved patient population and build structure to better manage that cohort.
The point is for the CIN to identify a population and their specific health care needs, ascertain the attendant costs in addressing those needs, and organize in a meaningful and purposeful way to address them, aiming for quality outcomes for the individual patient and the population as a whole. It is with this plan in mind that they can negotiate with the payer or participate successfully in a CMS/CMMI program.
Challenges
Because of their commitment to communication and care coordination, CINs can help to improve documentation, quality performance, patient outcomes, and physician accountability. With an increasing number of value-based contracts, these things help to ensure the providers maintain excellent care quality, lower the risk of decreased payor reimbursements, and can reap the rewards of appropriately lowered medical expense for their patients.
But this is where the challenges arise.
First and foremost, as in any entity, the incentive structure of the participating practices needs to align with the goals of the CIN. Financial incentives to practices – both PCP and specialist – need to promote the actions that lead to improved outcomes, lower costs, and discourage untoward utilization (over- or under-). And these incentives need to be real and paid early and often.
The processes and workflows for important tasks and clinical programming need to encourage their use rather than feel like another add-on to an already busy day. Also, this setup and maintenance can take a significant amount of data aggregation and analysis.
In other words, finds the means to get everyone in the boat rowing in the same direction.
To combat the challenges facing a CIN, free and easy exchange of clinical and claims information is essential, but that is easier said than done. The ideal flow of information within a CIN includes (at least) the following:
EMR information including current conditions plus recent and past testing
HEDIS Measure status by patient and physician
Up to date Pharmacy / Medication information
Scheduling and pertinent info flow for specialty consultations
Claims data for cost of care, AWV completion, and closed gaps
Real-time list of patients in need of clinical programming
Dynamic care management updates and status
More advanced CINs need a way to communicate timely remote patient monitoring (RPM) information, a preferred formulary of potential high-cost medications, and a preferred provider list for services not already offered within the CIN participants – and a way to track use of those last two should the CIN want to use them for incentive alignment.
Even with all physicians on the same EMR, the information stream above can be a challenge. The scary reality is that most CINs have numerous EMRs across their participants, compounding their obstacles. (The most I’ve heard is over 30 different EMRs, but I’m confident there are larger numbers out there).
All the above dynamic data points directly play into the performance of a CIN within its negotiated contracts. Failure to know, understand, and disseminate this information to the right points at the right time will likely result in missed metrics and lost revenue.
A word about Referrals
As physicians within a CIN consider the referrals to be made within the CIN, specifically those that are required by the CIN itself in its contract, policies and/or procedures, they need to ensure nothing can be construed as an inducement to furnish medically unnecessary items or services or, on the other hand, reduce or limit medically necessary items or services.
To protect against the appearance of inducement, CIN contracts need to accommodate the regulatory restrictions on physician referrals, including:
There can be no requirement to refer patients not part of the CIN and the value-based arrangement;
The referral requirement must be in writing; and
The referral requirement must not apply if the patient expresses a desire for a different provider or supplier, the insurer determines that a different provider or supplier must be used, or the physician determines a referral within the CIN is not in the patient’s best medical interests.
Cross the “t’s” and dot the “i’s.”
CONCLUSION
When set up and operated as intended, a CIN can be a very effective vehicle for allowing multiple, otherwise non-affiliated groups and organizations to participate in streamlining and optimizing healthcare delivery, avoiding extra or duplicative services, improving patient outcomes, accessing improved contracting with payers, and appropriately lowering the cost of the care rendered.
Of course, these arrangements are not to be created or entered into lightly, and all of the necessary processes, analysis, and reporting needs to be carried out by dedicated, knowledgeable people.
Beyond the trials of building and aligning a loose confederation of warring tribes, an effective CIN needs to solve the issues of data sharing and the timely, accurate, and free flow of information within the network. Doing so will help line up the work and incentives of the participants with the goals of the CIN – improved quality and outcomes, lower costs, and improved experience of all stakeholders.
