Reporting for value-based care initiatives like MACRA will start in less than a year. Smaller physician groups should be thinking about joining forces now.
The health insurance market has been evolving rapidly and we are now in an era of big data where insurance companies and employers alike are pushing for providers to manage patient populations by condition (or health status) and to do so in a highly coordinated way that produces optimal outcomes.
In order to meet such lofty goals, physicians are having to expand their horizons to include looking at populations larger than just individual patients walking through their doors. In fact, physician payment is now becoming dependent upon the management of patients, ensuring that the care they give is offered in a highly coordinated environment in order hold the line on costs and meet quality metrics. This is why physician practices should think seriously about becoming a clinically integrated network (CIN).
What is a CIN?
The Department of Justice and the Federal Trade Comission define clinical integration as an active and ongoing program to evaluate and modify practice patterns by CIN participants to create a high degree of interdependence and cooperation among physicians to control costs and ensure quality patient care. Generally, the FTC considers a program or organization to be clinically integrated if it does the following:
• Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care.
• Selectively chooses CIN 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.
There are predominantly three different types of CINs:
1. Hospital organizations
Typically a joint venture between a health system and its medical staff that is supported by health information exchanges (HIEs). These are the most prevalent type of CIN.
2. Health systems (hospital or payer)
These types of CINs operate like an accountable care organization (ACO), where the health system is the sole corporate member of the subsidiary entity and member physicians sign separate legal agreements to participate.
3. Independent Practice Associations (IPAs) or "super groups"
These are owned and operated by only physician members and/or partners.
The key to participating in a clinically integrated practice network is ensuring that the membership can work together to improve care, control costs, share data, and invest in care coordination and health information technology to ensure that population data can be tracked, utilized, and target metrics met.
Why the time to join a CIN is now
Many smaller practices and organizations are floundering as the healthcare market changes around them. Requirements for data reporting, care coordination, patient follow up, and so on, in order to meet new market and contracting demands is becoming too costly and cumbersome to support. Many smaller groups have little leverage in the market to secure good contract terms with both payers and hospitals that are building ACOs and limiting employee benefits to narrow networks -so coming together under these structures is a good way to share the load.
Being part of a larger network of high performing (that is, ability to meet market quality metrics) providers improves leverage, minimizes participation costs, and allows for data to be managed centrally; which can help with CMS reporting, commercial payer pay-for-performance compliance, and patient tracking and management, for example. It is expensive to manage to metric-driven contracts, so utilizing CIN data mining across EHRs from multiple vendors helps to reduce that burden substantially. And if you can't manage to the data, you can't take advantage of performance initiatives and may be facing payment penalties in the months to come.
So if you are an independent physician, you may want to see what options are available to you to partner up with larger physician groups, hospitals, or health systems that can help you thrive in the big data market. Now is the time.