Clinically integrated networks: Guidelines and common barriers for establishment

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A 2007 article in the New England Journal of Medicine found that the average Medicare patient saw a median of two primary care physicians (PCPs) and five specialist physicians per year. These numbers illustrate the consequences of poor communication between providers, and the resulting excessive costs seen in medicine. 

Because of this increasing cost of care, many payers decreased reimbursement of fee-for-service and increased value-based payments, illustrating a focus on delivering better healthcare at lower costs (Strilesky), (Krivopal). An increasingly popular approach to meet this goal is the establishment of clinically integrated networks (CINs). Compared to other physician organizations, CINs can provide unique benefits to the physicians involved, as well as patients under their care. 

CINs are networks of providers that share information via EHRs to improve quality of patient care, reduce costs, and demonstrate value in the healthcare marketplace (Pofeldt). Typically physician-led, CINs can be composed of employed and/or independent physicians and can also include partnerships with healthcare systems. Leadership within a CIN will establish clear goals and objectives, as well as participation guidelines for members to meet the demands of the ever-changing healthcare landscape.

Benefits of a CIN

Many benefits of CINs are linked to the improved opportunities for team-based patient care. Because of the increased prevalence of the hospitalist model, the current healthcare landscape makes it difficult for PCPs to interact with specialists who share their patients. CINs help mitigate this problem by connecting these physicians to each other, leading to better communication between healthcare providers. This increase in connections between physicians and a shift toward team-based care can also translate into enhanced access to resources for patients. For example, some CINs have implemented alert systems that will notify PCPs if one of their patients visits the emergency department, allowing for faster follow-up care. 

Another major advantage of CINs is that they can negotiate with payers on the physician’s behalf, potentially improving reimbursement rates. By continuously collecting and analyzing data, CINs allow for the creation of tangible data that can be utilized to satisfy performance metrics and demonstrate their value in the market. CINs also allow independent physicians to maintain their individual practice while gaining access to resources and pooled data that would otherwise be unavailable to them. This positions physicians to make informed decisions on best practices to improve patient outcomes, which should lead to greater reimbursement in the value-based care era. Some CINs have even established chronic disease registries that collect data in an effort to lower costs on frequently encountered high-cost chronic illnesses.

To establish and grow an effective CIN, participating physicians typically will invest some of their own finances in the form of either initial membership fees or annual fees. Each physician will also provide other resources such as time and energy in order to contribute to the overall goals of the CIN. To help offset the time and financial investment by participating physicians, many CINs have robust financial incentive programs in place. These incentives are commonly based on cost savings and meeting quality metrics set by the CIN. This can help incentivize physicians to utilize the resources provided by the CIN and actively participate in the CIN.

Guidelines for establishing a CIN

Because CINs allow for negotiation with payers for better reimbursement rates, an inherent risk of reducing competition in the marketplace and increasing healthcare costs arises (Brooks, et al). To mitigate this risk, in 1996 the Federal Trade Commission (FTC) provided guidelines (which have since been periodically updated) for establishing healthcare organizations to prevent violations of the Stark Anti-Trust Laws. 

According to the guidelines, a CIN should include (Donovan), (Gallegos):

• 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.

The available legal options for establishing a CIN include physician-hospital organization, independent practice association, or subsidiary of the health system (Butcher). All of these options can be utilized to meet CIN goals and objectives, but each differs in ownership structure and canalization requirements. 

If a CIN utilizes partnership with a hospital organization, it is critical that physicians are involved in leading that CIN. This will lead to increased cooperation between hospitals and physicians as well as allow physicians to have a major say in the future directions of the CIN. In addition, working toward the goals and objectives of a CIN will require participating members to change much of their practice including participating in data sharing through EHRs with other members of CINs and changes in referral practices. Physician leadership can also more effectively guide members in implementing these changes into their practice. 

Barriers to establishing successful CINs 

Because CINs are often comprised of a mix of employed and independent physicians utilizing different EHR systems, pooling data across all providers into one organized, easily accessible database becomes a major hurdle-one that requires significant infrastructure and information technology support to overcome. 

There are different options available for participants to share their data, including using additional software to connect each individual system or manually downloading and entering data. But since these options often require additional steps and cost time and resources, a suggested strategy is to survey all participants to identify most common EHRs used in the network and use that information to pinpoint the easiest and cheapest alternative.  

Once a database is established, continuous data collection and analysis must occur to identify best practices and areas for cost reduction, so a significant amount resources and time are spent before any meaningful outcomes are realized. This means there is a long waiting time before physicians see any return on their investment, including cost savings or reimbursement bonuses. Because of this, it is critical to set clear and realistic expectations for physicians entering into an agreement to join a CIN. 

Many CINs have also failed to allocate the necessary resources, such as effective use of EHRs, and personnel to measure return on investment from care management activities and resource utilization, leading to struggles negotiating with payers. CINs therefore must be willing to allocate necessary resources in order to demonstrate continual clinical improvement and effective management of total cost of care. 

Participating physicians have a larger referral network for their patients, but many CINs fail at utilizing this network to improve referrals. Many physicians may be used to a specific practice in referring patients, and a particular CIN may not be putting enough emphasis on more effective referral within their CIN. A recent article published by advisory board stated that a specific 13-hospital CIN found that more than 40 percent of their employed physicians were referring patients to non-network providers. This not only led to loss of potential revenue for care provided, but also loss of valuable information for each patient sent out of network. It is critical for a CIN to make effective referral management a major goal as well as provide members with easily accessible information about physicians in the CIN. 

Conclusion

Over the past few years, CINs have become an increasingly popular solution to challenges in the healthcare marketplace. CINs offer many benefits for participating members, including interconnectedness between healthcare providers; contributing to data-driven, evidence-based best practices; increased savings and reimbursement bonuses; and the potential for improved reimbursement from payers. These benefits also extend to patients under the physician’s care. Although CINs can potentially be a great model, there are many barriers to their implementation. They require a large time and resource commitment from members, clear goals and objectives set forth by their leadership, and an organized and efficient technology component for continued management and analysis of data. If these challenges are met, CINs can be a great solution to improve physician and patient wellness.