In healthcare reform, the shift from fee-for-service to value-based reimbursement is driving the most profound changes in the healthcare industry. Recent legislation such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is compelling health care organizations to consider more creative and viable alternatives to address concerns regarding quality, cost, and value. Clinical integration may be the way to meet the evolving complex challenges of health care reform.
Becker’s Hospital Review, in an article entitled “The 7 Components of a Clinical Integration Network,” explained 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.”
Clinical integration is to healthcare what innovation and technology breakthroughs are to product manufacturing and service delivery industries.
Defining the Clinically Integrated Network
In response to the challenges of reform in health care, many providers find themselves joining with other physicians to form Clinically Integrated Networks (CINs). A CIN is a legal entity structured to enable approved collaboration and cooperation among health care providers. Possessing shared goals that encompass value, efficiency, performance, and quality, CINs can garner competitive advantage while achieving better quality and more efficient coordination of care at a more affordable cost. The goal is to be able to negotiate a more favorable reimbursement rate.
The highly coordinated environment of a CIN is able to deliver market value through the health care network as well as provide value/risk contracts by improving the management of the MACRA Quality Payment Program and other state and commercial payment model alternatives. Furthermore, a CIN offers physician independence by providing an alternative to employment for independent community physicians. With a CIN, hospitals, physicians (both employed and independent), and other care providers can coordinate more easily and can work together to meet clinical and financial goals. Also, a CIN enables effective management of population health and coordination of care on a comprehensive scope.
What are the primary characteristics of a CIN?
According to the U.S. Department of Justice, a CIN has four main characteristics:
1. Leadership Teams That Include Physicians
CIN governance models must have physicians incorporated into its governing vehicle. Both private and employed physician practices are eligible to form a CIN.
2. Clinical Standards
All CIN members must officially agree to adhere to clinical guidelines and work on activities that improve performance. Performance improvement relates to all aspects and overall approach to care, including quality of treatment, accuracy, efficiency, timeliness, outcome, and satisfaction.
3. Information and Technology
The correct technologies and tools must be utilized to gain the network visibility necessary to transport clinical integration from theory to reality. To provide more coordinated care, information-sharing and performance monitoring are required. CINs need visibility across the care continuum to measure and analyze performance and patient outcomes.
4. Defined and Measurable Improvement
The CIN must demonstrate it is elevating value, not just using its size to negotiate better rates from payers. CINs use data analytics to identify and prove when performance objectives are met and use that information to negotiate superior reimbursement rates.
As health care reform continues to head in the direction of quality and value, CINs will play a central role in the process. Hospitals and physicians should carefully examine whether a CIN offers them the best path to satisfy the “Triple Aim” while being careful not to disrupt value through investment and reimbursement reduction.
Health care providers must develop and perfect care-delivery and value-based models that are effective and efficient to obtain the broader objective of achieving high-value care for patients.
CSuite Solutions works with healthcare providers throughout the United States to deliver innovative solutions that improve patient care while driving efficiencies and profitability. The professional healthcare system advisors at CSuite Solutions assist with direct-to-employer self-funded insurance plans, value-based care, revenue cycle management, and accountable care organizations. Founded by leading C-level healthcare executives with many years of experience, CSuite Solutions is expertly placed to work alongside healthcare systems in an advisory capacity.