In general, the FTC considers a network to be clinically integrated if it:
- establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure the quality of care.
- selectively chooses CI network physicians who agree with efficiency objectives.
- makes significant investments, both financial and human, including shared risk in developing the infrastructure and capabilities necessary to achieve collaboration and care efficiencies.
Legal and policy experts have identified six core requirements:
- Implement information systems to measure and report to payers on quality, utilization and cost effectiveness of care across the physician network.
- With significant physician involvement and leadership, develop and implement clinical protocols and guidelines to govern treatment and utilization across a wide range of disease states.
- Regularly evaluate both individual physician and the network’s aggregate performance and manage that performance through financial incentives, enforcement policies and ongoing eligibility for network participation.
- Develop care management, pre-authorization and related functions to manage utilization within the network.
- Invest adequate capital to purchase the information systems necessary to gather aggregate and individual data to measure and track performance.
- Engage physician leadership through appropriate physician governance.
In our experience, high performing CINs have deployed the technologies that can electronically capture and monitor achievement of the goals and objectives of the CIN. This can include, and is not limited to, the ability to electronically stratify populations at risk, identify gaps in care and share information across all participants (including patients, physicians, nurses, care coordinators and hospitals). The information and analysis is used to coordinate care delivery, identify trends and improve performance for the entire care continuum for each patient. High performing CINs also are keenly driven towards providing timely access and a patient experience that creates a high level of satisfaction.