What is a Clinically Integrated Network and what are its primary characteristics?

By nThrive | Posted: 02/19/2018

The health care landscape is undergoing dramatic change, driven in part by health care reform’s shift from fee-for-service to value-based reimbursement. Recent legislation such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is challenging health care organizations to explore additional alternatives to address concerns related to cost, quality and value, with many turning to clinical integration to tackle the evolving complexities of health care reform.

In its article, “The 7 Components of a Clinical Integration Network,” Becker’s Hospital Review defined clinical integration as “a health network working together, using proven protocols and measures, to improve patient care, decrease cost and demonstrate value to the market.”

The goal of clinical integration is simply to bring hospitals and physicians across the care continuum together to support the Institute for Healthcare Improvement’s “Triple Aim” objectives of improving the patient experience of care, improving the health of populations; and, reducing the per capita cost of health care.

What is a Clinically Integrated Network (CIN)

To respond to the challenges of health care reform, many health care providers are joining with others to form Clinically Integrated Networks (CINs). A CIN is a legal structure that facilitates sanctioned collaboration among health care providers. With shared goals in performance, quality, value and efficiency, CINs help providers remain competitive promoting higher quality, better coordinated care at more affordable cost with the goal of achieving superior reimbursement rate negotiation.

A CIN’s highly coordinated environment has the power to deliver:

  • Market value by creating a low-cost, high-quality unified health care network destination.
  • Value/Risk contracts by enhancing the ability to manage the MACRA Quality Payment Program and other state and commercial alternative payment models such as Bundled Payments, Shared Savings, Direct Contracting, etc.
  • Physician independence by providing an alternative to employment for independent community physicians.
  • Coordination by making it easier for hospitals, employed and independent physicians and other providers to work together to reach clinical and financial goals.
  • Population Health by enabling effective population health management and care coordination across the full care continuum.

What are the primary characteristics of a CIN?

According to the U.S. Department of Justice, a CIN has four main characteristics:

1. Physician Led

A CIN must have physician leadership incorporated into its governance model. Both private and employed physician practices are eligible to form a CIN.

However, the U.S. Department of Justice and Federal Communications Commission have set very stringent requirements for how an acceptable CIN organization can be formed. The three acceptable organization options are Joint Venture Physician-Hospital Organization (PHO), Health System Subsidiary, and Independent Practice Association. A CIN’s organizational options vary based on shared percentage of profitability between the health system and participating physician or hospital.

For instance, the payor or employer contracts directly with the Joint Venture PHO CIN and the profitability is distributed to the two different organizations. The other two options differ in that the major share of profitability is distributed to one organization over the other. The health system receives the profit in a Health System Subsidiary CIN whereas in an Independent Practice Association the participating physicians would profit. There are various reasons for choosing one option over the other, but the most common CIN is the Joint Venture PHO. Whatever legal structure the organization takes, it must be physician-led.

2. Clinical Guidelines

All CIN members must formally commit to complying with clinical guidelines and working on performance improvement activities. Performance improvement relates to all aspects and overall approach to care including treatment quality, accuracy, efficiency, timeliness, outcome and satisfaction.

3. Data and Technologys

The right technology and tools must be employed in order to gain the cross-continuum visibility necessary to move clinical integration from concept to reality. To provide more coordinated care, data sharing and performance monitoring are required. CINs need visibility across the continuum of care to measure and analyze performance and patient outcomes.

4. Measurable Improvement

The CIN must demonstrate it is improving value, not just using its size to wrangle better rates from payers. CINs use data analytics to identify and prove when performance objective goals are met and use that information to negotiate superior reimbursement rates.

As health care reform continues to drive toward quality and value, CINs will play a central role in the process. In a recent nThrive educational webinar, Senior Consultant Scott Jones cautioned “if you build it they won’t necessarily come.” Hospitals and physicians should carefully examine whether a CIN offers them with the best path to satisfy the Triple Aim while being careful not to disrupt value through investment and reimbursement reduction.

Health care providers need to continue to develop care-delivery and value-based models that are effective and efficient to achieve the overarching goal of achieving high value care for patients. To learn more about CINs, click here to view the educational webinar, Quality Payment Program: Path to Clinical Integration.