In 1996, the DOJ and the FTC defined Clinical Integration (CI) as an active and ongoing program to evaluate and modify practice patterns by the CI network’s physician participants. Consequently creating a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. Generally, the FTC considers a program to be clinically integrated if it performs the following:
- Establish mechanisms to monitor and control utilization of healthcare services. As a result they allow you to control costs and ensure quality of care
- Selectively chooses CI network physicians who are likely to further these efficiency objectives
- Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies
Key Success Factors for a CIN
CIN must create a sufficient value proposition (i.e., for regional health systems, hospitals, physicians, payers, the community, and employers)
- Need to develop partnerships outside of CIN entity – Primary care of particular importance.
- Technology: Maintain systems that can track and monitor clinical and claims data across the continuum of care. For instance, ambulatory, acute, post-acute services, home, etc.
- Create an effective communication strategy across all stakeholders. Thus increasing understanding of the key issues of CI, workgroup activity, provider performance, and peer-to-peer capabilities
- Develop a fair, tiered incentive program
- Continue ongoing discussions / pursue value-based contracting with payors
- Compliant legal structure
- Cultural shift in the mindset of FFS to FFV practices
- Physician Compliance for instance, rewards as well as disciplinary action if necessary
- Physician engagement
- Strong data analysis capabilities and resource utilization management
The Benefits of Clinical Integration
Autonomy within collaboration
A CIN enables autonomous medical practices to participate in collaborative care teams. As a result this allows you to measure comprehensive quality outcomes.
Enhanced payer relationships
CIN’s provide a creative value with payers. As a legal entity, a CIN can contract for enhanced reimbursement through shared savings and/or performance incentives.
Population Health support
A CIN can provide the technology to track quality outcomes. Therefore, Quality Outcomes are the organizational structure to integrate care management with other providers. Specifically, this includes the tools to identify and influence the cost of care. Assists in providing better care to patients in the community
Protection against payment risk
Physicians who align themselves with a CIN will stay on the forefront of opportunities to benefit from new contracting approaches. As well as, new reimbursement structures and new ways to maintain accountability for contract performance.
- Positions physician practices with the resources needed as payment reforms unfold
- Opportunity to join with others to prepare for “Value-Based” Market Changes
- Minimizes insurance company intrusiveness
- Opportunities to take advantage of value-based incentive programs such as PQRS assistance
As a CIN matures, “leakage” of patients outside of the network should decrease 10% to 15%. After that, hospitals should also see a decrease in their utilization
Proactive Pursuit of FFV Contracting
Payers are beginning to offer complementary insurance products that leverage population health management
There is a due diligence period to assess your organization’s current capabilities. This is to locate the necessary steps to be taken when composing a strategy around becoming a CIN. For instance, these areas of focus include:
- CIN Legal Transition: Evaluate legal documents and structure to attain a legal advisory opinion
- Network Management & Operational Infrastructure:
- Ensure the proper tools are in place to manage the abundance of provider documentation
- Assess appropriate governance and committee structure
- Create proper documentation and policies and procedures
- Technological Infrastructure & Reporting: Ensure the necessary tools are in place for providers to gather and submit data, perform clinical and cost analytics. Consequently, these support clinical performance improvement initiatives
- Clinical Programs: Initiate data-driven programs in correspondence to the needs of your community
- Strategy: Managed Care and Local Employers
- Physician Engagement: Physician participation and leadership structure
- Community Engagement: Information sharing and leading as a voice. Indeed, to drive community health initiatives
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