The coming sea change toward value-based reimbursement has created a tsunami of buzz over clinically integrated networks, or CINs. Most hospitals would like to form one. Many physicians would like to join one. But let's face it. Achieving a meeting of the minds between providers who have always valued self-regulation and independence can feel a bit like building the Great Pyramid from the sand up.
In a previous post
, I discussed my experiences as chief medical officer of a Coordinated Care Organization (a type of CIN) created to manage the health of my county's Medicaid population. In this post, we'll take a closer look at the building blocks of a CIN and discuss how hospitals can foster success at each step of the construction process.
Fundamentally, a CIN is a group of primary care, specialty and mental health providers who work together to coordinate patient care and streamline its delivery.
Unlike managed care organizations of the past, which mainly addressed utilization, CINs are designed to reduce per capita costs while maximizing clinical outcomes. Participating physicians are expected to adhere to standardized care protocols and work toward shared performance goals. Both the network and the individual physicians can maximize their earnings through positive performance.
The Institute for Healthcare Improvement
has identified clinical integration as a key to achieving its triple aim of population health, cost reduction and patient experience.
Becker's Hospital Review recently defined the seven key components
of a clinically integrated network. Let's examine each of these in light of some of the lessons we've learned from pioneering CINs across the country.
Requirement 1: Legal Option
Habit: Lay a firm contractual foundation
To pave the way for collective bargaining and shared savings, every CIN must formalize itself as a legal entity. This usually takes the form of a joint venture between health systems, hospitals, independent practice associations (IPAs) and/or individual physician groups.
Both the CIN's structure and its day-to-day functioning are determined by contractual relationships that spell out participants' obligations, responsibilities and rewards. For example, what are the network's performance goals? What are its success criteria? How will performance of both the network and individual physicians be measured and reported? How will shared savings be distributed?
Building detailed performance expectations into the management contract can greatly enhance a CIN's effectiveness. Which brings us to an important point ...
Requirement 2: Physician Leadership
Habit: Physicians and administrators co-design the network architecture
When hospital executives meet with the medical staff to discuss clinical integration, they often walk away frustrated. This is because when it comes to clinical matters, physicians listen to other physicians, not administrators. For this reason, it's absolutely crucial that a CIN be physician-led.
In the development stages, physician champions help create buy-in. They can help colleagues understand that change is imminent and that the days of fee-for-service reimbursement are numbered. They can articulate how joining forces to improve quality and efficiency will benefit patients and maximize value-based payments for participating providers.
The need for physician leadership continues once the network becomes operational. Empowered and aligned physicians can catalyze peers to collaborate across departments and craft big-picture solutions to the challenges facing hospitals. To foster this sort of engagement, hospitals can include respected physicians in the CIN's board membership and tap key influencers to lead improvement initiatives and committees.
Requirement 3: Participation Criteria
Habit: Cultivate transparency
In order to take advantage of the legal and collective bargaining benefits conferred by CIN status, the Federal Trade Commission requires the network to limit participation to those physicians most likely to achieve its quality goals. For this reason, each CIN must establish detailed participation criteria and bind participants to these through a formal agreement.
In my experience, lack of transparency is often the biggest roadblock providers face in the journey to CIN participation. Historically, outpatient physicians haven't been subject to the same accountability measures as their hospital-based counterparts. Hence they may not be aware of how their costs and patient outcomes stack up against their peers.
Again, this is where physician leadership pays off. Outpatient providers are far more likely to embrace transparency with the practice is championed by trusted colleagues. Which brings us to another important point ...
Requirement 4: Performance Improvement
Habit: Provide peer support
CIN participation allows physicians to take the lead in defining and achieving quality. Through protocol development, process engineering and performance monitoring, physician leaders have the opportunity to reshape the entire spectrum of acute care.
As with participation criteria, improvement initiatives can be daunting for providers who have never monitored their own practice habits. Sharing performance data with peers may feel like an invasion of privacy and autonomy.
Yet again, this is a case where physician leadership makes all the difference. An orthopedic surgeon with a high cost per case will be far more receptive to feedback from a peer than an administrator. The physician leader can help the surgeon understand how reining in costs will benefit all stakeholders. These leaders can also use their influence to create a culture in which transparency is seen as positive rather than punitive.
Requirement 5: Information Technology
Habit: Invest in business intelligence
For a CIN to succeed, it must be able to glean meaningful intelligence on costs, outcomes and disease processes from electronic health records and centralized patient registries. In the early stages, this may mean writing explicit standards for IT infrastructure into each members' performance agreement. Later, it may mean outsourcing data mining and analysis to a third party. While these services cost money, they also free providers to focus on patient care and quality improvement.
Requirement 6: Contracting Option
Habit: Prepare now for value-based reimbursement
CINs offer providers a vehicle for managing population health, allowing them to align preemptively with the looming shift toward outcome-based payments. CINs have the opportunity to contract with payers and employers on a population basis, enabling them to make a measured transition toward value while still supported by a fee-for-service safety net.
Requirement 7: Defined Distribution Scheme
One of the oft-raised objections to fixed payments is their potential to create a feeding frenzy
among hospitals, providers and others involved in an episode of care. Based on my own experience, the best advice I can give is to keep it simple. Distributions should be based on measurable performance criteria, and the formula should be clear to all participants as well as external auditors.
What's more, the distribution scheme should be transparent across the network. Everyone must know how everyone else is paid and whether they’re on target.
The Power of Leadership
While building a CIN can feel monumental, pioneering organizations are beginning to untangle some of the thornier knots in the process. Legal, structural and cultural barriers to integration remain, but strong physician leaders can do much to align the various medical groups affiliated with their hospitals. For this reason, hospitals are wise to seek out those groups with a demonstrated track record of leadership, engagement and collaboration.