The six key elements of properly integrated networks.
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Published 7/1/2017
John N. Wood, PhD; Alexandra E. Page, MD

Maximize Benefits, Minimize Risk Through Clinically Integrated Networks

Although clinically integrated networks (CINs) have been around for decades, their popularity appears to be on the rise, coinciding with the increase in alternative payment models (APMs) and value-based care initiatives. That's because CINs offer both patients and physicians—including specialists such as orthopaedic surgeons—many tangible benefits.

Patients receiving care via a CIN typically have a single point of entry during which their medical history and current symptoms are recorded. This information is then transmitted, along with additional clinical information, to other members of the care team behind the scenes. These coordinated hand-offs enable patients to enjoy a streamlined care process, faster service, and typically, better outcomes.

Patients are not the only winners, since clinicians practicing within a CIN also benefit from the arrangement. CIN patients arrive as high-quality referrals with a detailed history and care summary. Additionally, the provider is equipped with up-to-date care guidelines provided by the CIN and can often systematically update these guidelines based on experiences within his or her own patient population.

Whether caring for patients or working behind the scenes on network matters (such as developing or improving care guidelines), clinicians within the CIN also benefit from working with an extended team of hand-selected members who share common values. This alignment of goals, incentives, and approaches can lead to more fulfilling and efficient experiences for all members of the provider team.

Passing the test
Often used as a gateway to APMs and value-based care initiatives, CINs also provide physicians the ability to pursue risk-based contracts. A goal of the Centers for Medicare & Medicaid Services (CMS) is to provide 50 percent of Medicare reimbursements through APMs by 2019. CMS projects this figure will rise to 75 percent by 2021. Not only will physicians operating within a CIN have the opportunity to capture large segments of the market, they'll also have the opportunity to receive additional incentive payments of 5 percent for 2017 and 2018.

In addition, integrated physician groups typically have stronger negotiating power with commercial payers that are also transitioning from volume to value-based reimbursement models. However, this negotiating power is also a potential downside to integration because it exposes the network participants to potential lawsuits regarding antitrust issues. Due to antitrust tort complexity and the seriousness of consequences, physicians intending to form a CIN are highly encouraged to consult with an experienced antitrust attorney. Although legal opinions often vary, two rules of thumb that are generally accepted among the antitrust legal community are the per se test and the rule of reason.

The per se test seeks to answer the question: Does the arrangement engage in behaviors considered blatantly anticompetitive? Items that fall under the per se test are assumed to harm consumers. In contrast, the rule of reason seeks to answer a series of questions: First, does the arrangement engage in behaviors considered anticompetitive? Second, are those behaviors reasonably related to the pro-competitive benefits and reasonably necessary to the realization of the pro-competitive benefits? Finally, does the arrangement give market power to the participants?

To provide healthcare context to antitrust matters, the Department of Justice and the Federal Trade Commission jointly released "Statements of Antitrust Enforcement Policy in Health Care" in August 1996. More recently, but with similar intent, the agencies released the "Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program" in October 2011. Although neither of these documents prescribe bullet-proof models, they do provide descriptions of integrated networks that have withstood antitrust legal scrutiny. According to information in these documents, properly integrated networks contain the following six key elements:

  1. significant capital investment
  2. mechanisms to measure utilization and quality
  3. practice protocols designed to improve care
  4. information systems that support data collection, decision making, and care delivery
  5. disciplinary procedures for underperforming physician members
  6. selection procedures for adding new physician members

Capital investment includes both the monetary and human capital needed to create the infrastructure necessary for measuring key aspects of care delivered, enabling demonstrable improvements in those areas, and documenting evidence of success. Well-designed CINs will employ mechanisms to measure key aspects of care such as patient experience, patient safety, individual outcomes, population health, and the cost of care. These data points are then used to establish performance goals for individual physicians and the group as a whole. The data points are also used to inform network-wide decisions related to controlling costs while ensuring or improving quality of care. Such decisions are typically disseminated via the publication of practice protocols and clinical practice guidelines.

Additional considerations
To support the collection of performance metrics and the execution of published guidelines, successful CINs employ information systems. Although the use of common electronic health records among physician members may be beneficial, it is not a necessity. Regardless, the CIN should have standard systems consisting of people, processes, and technology for measuring and monitoring performance at the individual and group levels, as well as systems for sharing clinical information among physician participants.

When the performance level of a physician member falls below the CIN's defined standard of care, the CIN leadership must enforce established disciplinary procedures. These procedures should include escalation measures up to and including the eventual termination of members who continue to underperform. In an effort to avoid the need to discipline members, successful CINs are very selective when recruiting physician members to join the network. These CINs are guided by written procedures that describe how a potential physician member will be identified, what quality benchmarks will be evaluated prior to his or her acceptance into the network, and additional indicators that may determine whether or not the physician's behavior aligns with that of other members of the network.

CINs are rising in popularity for good reason. Proper integration results in a multitude of benefits for patients, clinicians, and their corresponding business entities. In addition, the need for CINs is expected to grow due to the ongoing trend among government and commercial payers to shift from volume- to value-based payments. However, as with many other aspects of the medical field, there are legal dos and don'ts. By designing a CIN around the six key elements described above in consultation with an experienced antitrust attorney, physician members will be well prepared to enjoy the benefits and minimize the risks associated with clinical integration.

John N. Wood, PhD, is the founder and chief executive officer of Cardinal Point Healthcare Solutions; Alexandra E. Page, MD, chairs the AAOS Health Care Systems Committee.

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