Clinical Integration - Frequently Asked Questions
1. What is clinical integration?
Clinical integration is a new model for health care delivery. The model promotes collaboration among a community's independent providers to furnish high quality care in a more efficient manner. Physicians, hospitals, and other providers share responsibility for, and information about, patients as they move from one setting to another over the entire course of their care. Working together, clinically integrated providers develop and implement evidence-based clinical protocols, focusing on delivery of preventive care and coordinated management of high-cost, high risk patients. Utilizing shared information technology, these providers conduct ongoing clinical care reviews to identify opportunities for improvement and ensure adherence to protocols. While the antitrust laws generally prohibit joint contract negotiations among independent providers, those laws permit clinically integrated providers to engage in collective negotiations with health plans. Working together, these providers can more effectively compete for payer contracts because they demonstrate high quality and greater efficiency in care delivery.
2. What is a clinically integrated network, or CIN?
A clinically integrated network is the infrastructure needed to support clinical integration among a community's independent providers. The network develops a governance structure through which these providers come together to decide on protocol development and implementation, performance measurement and enforcement, and formulas for rewarding performance. Other network activities include, for example, identifying, implementing, and maintaining supportive technologies (including data analytics); analyzing care processes to identify efficiencies; encouraging patient engagement; negotiating pay-for-performance payer contracts; and distributing incentive payments to members.
While a hospital can provide administrative expertise for a CIN, network leadership is shared with physicians. Only physicians have the knowledge, skill, and experience needed to achieve improvements in clinical quality and efficiency. Unlike organizations such as integrated delivery networks (with hospital-employed physicians) and large multi-specialty physician practice groups, which base their clinical integration strategies on economic integration, a CIN respects and preserves the economic independence of its physician members.
3. Who is responsible for forming the CIN in our community?
In late 2012, the Flagler Hospital Board of Directors requested the physician community to make recommendations regarding formation of a CIN in our community, requesting a report be made in early Spring. The Board appointed a physician committee to perform the limited task of facilitating this planning process; the committee and its members have no authority beyond that defined role. The hospital is bearing the costs associated with this initial planning phase, including consultants' fees and meeting expenses. Also, the hospital is paying physicians on an hourly basis for time spent on this endeavor.
This physician committee, known as the Clinical Integration Committee, or CIC, now is developing those recommendations. The CIC's work is supported by several work groups, including Governance, Quality and Operations, Communications and Network Development, Technology, and Finance and Administration. The CIC's activities are coordinated by an Executive Committee.
Several medical staff members have accepted leadership roles in this planning process. However, those individuals will not necessarily have similar roles in the CIN. Part of the recommendations to be made will address CIN governance, including the manner in which its leaders will be selected. Although the hospital is making a significant initial investment, the board of directors fully appreciates the CIN must be led by physicians. A CIN's primary function is clinical, not administrative. While the hospital is prepared to provide necessary administrative support, the process must be driven by clinicians.
Physicians participating in the CIC attended a two-day retreat in early February to discuss the CIN governance structure and the specific functions the CIN would perform. The work groups now are drafting their recommendations for consideration by the full CIC.
The full CIC will approve the final recommendations to be submitted to the Flagler Hospital Board of Directors in late March. Assuming the Board accepts those recommendations, work will begin immediately to form the CIN.
4. How is it lawful for a CIN to collectively negotiate with payers when the Federal Trade Commission (FTC) is actively investigating and prosecuting providers for collusion?
Provider worries about federal regulators are well-grounded. Since 2001, the FTC has prosecuted more than 30 independent practice associations and physician hospital organizations alleging pricefixing arrangements. The FTC, however, views provider collaboration through a CIN very differently than collusion among independent providers. To the extent joint contracting is both necessary and subordinate to a CIN's broader effort to improve quality and efficiency, the federal agencies view these arrangements as beneficial to consumers and pro- competitive. Thus, providers' full commitment to achieving critical integration is critical.
5. What are the key characteristics of a CIN?
- Well-defined governance structure to promote organizational goals while protecting individual
- Physician-driven, professional management.
- Data driven.
- Relentless focus on improving the health of the population served.
- Adherence to evidence-based medicine guidelines and clinical protocols.
6. Why has interest in CINs grown so rapidly in the last several months?
The health care payment and delivery system is undergoing fundamental changes. Currently, a provider is paid for the individual services furnished by that provider. Such volume-based reimbursement offers no economic incentive for providers to work together in providing patient care. However, payers now are shifting to value-based reimbursement, i.e., rewarding providers that deliver high quality care in an efficient manner. The Centers for Medicare and Medicaid Services (CMS) is promoting this transition in the Medicare program through a number of initiatives authorized by the Affordable Care Act. These include, for example, the Medicare Shared Savings Program, hospital physician value-based purchasing, and bundled payments. Following the Supreme Court's decision on the ACA and President Obama's re-election, it appears these initiatives will move forward. Commercial insurers, as well as employers, also are aggressively pursuing value-based purchasing arrangements. More and more payers are introducing pay-for-performance provisions in their standard provider agreements.
Achieving measurable improvements in quality and efficiency demanded under these new payment models requires coordination and collaboration among a community's providers. A CIN provides a vehicle for independent providers to work together for these purposes while protecting their individual interests.
7. How is a CIN different from an accountable care organization (ACO)?
The term clinically integrated network dates back to the mid-1990s, when the Department of Justice and the Federal Trade Commission first acknowledged independent providers working together to improve quality and efficiency could engage in joint payer negotiations.
The term accountable care organization was first used about a decade later in reference to a group of providers that assumes responsibility to provide care for an assigned patient population. Typically, an ACO bears some financial risk associated with providing such care.
Generally speaking, an ACO is a more formal arrangement, structured to satisfy specific payer requirements. For example, only an ACO that meets certain regulatory requirements is eligible to participate in the Medicare Shared Savings Program. A CIN may elect to form an ACO for purposes of contracting with a particular payer. That decision, however, may be deferred until the CIN is fully operational.
Currently, there are forty-two ACOs operating in Florida, the second-highest number in the nation. Some of these ACOs are participating in the Medicare Shared Savings Program, while others are contracting with private insurance companies.
8. How do the fraud and abuse laws impact a CIN?
The federal Anti-Kickback Statute, the Stark Law, and the Civil Monetary Penalties Act (collectively referred to as the fraud and abuse laws) place restrictions on relationships among health care providers. For example, any financial relationship between providers must be based on fair market value for the goods or services provided.
Any financial relationship created as part of the CIN will have to be structured in a manner to comply with the fraud and abuse laws. The CIN does not provide any special protection from the civil and criminal penalties associated with violations of these laws.
9. What is the Medicare Shared Savings Program (MSSP)?
An ACO that participates in the MSSP and meets certain quality standards is eligible to receive a portion of any savings generated through improved efficiencies in care delivery. CMS measures these savings based on its annual expenditure per beneficiary assigned to the ACO as compared to a historical benchmark. Beneficiaries are assigned to an ACO based on their primary care physician.
In addition to eligibility for shared savings, an ACO participating in the MSSP enjoys waivers from the Anti-Kickback Statute, the Stark Law, and the prohibitions on gainsharing and beneficiary inducements, all of which now serve as barriers to provider collaboration. (Groups of providers organizing for purposes of participating in the MSSP also benefit from these waivers.) As a result, ACO participants can enter into financial arrangements otherwise prohibited by law.
If the CIN elects to pursue participation in the Medicare Shared Savings program as an ACO, it would enjoy significantly greater flexibility in structuring relationships among its member providers.
Currently, there are more than 250 ACOs participating in the MSSP, covering up to 4 million Medicare beneficiaries.
10. How do pay-for-performance contracts and shared savings programs work?
Under a pay-for-performance contract (often referred to as a P4P contract), an individual provider continues to submit claims and received fee-for-service reimbursement. If the provider achieves a certain goal specified in the contract, the provider receives an additional incentive payment. A P4P contract may provide for a penalty if a provider fails to meet a specified target. The Medicare Physician Quality Reporting System ("PQRS") is an example of a P4P program. Under PQRS, a physician will receive a 0.5 percent bonus payment if he or she submits a report on specified quality measures in 2013. If, however, a physician does not submit such a report in 2013, that physician will be penalized 1.5 percent on Medicare payments in 2015. Many commercial payers are looking to include P4P provisions in their contracts with individual providers. Generally speaking, a CIN can negotiate more favorable P4P terms. Also, a CIN supports an infrastructure that enables its members to achieve P4P measures. Under a shared savings program, a network of providers is eligible to receive a portion of a payer's savings generated by improved quality and efficiency. This is accomplished through a multi-step process:
(1) The payer assigns a specific patient population to the CIN, usually based on the patients' primary care provider.
(2) Providers in the CIN continue to receive fee-for-service reimbursement for all services, including services for patients in the assigned population.
(3) The payer calculates a benchmark rate based on the payer's historical cost of providing care for that population.
(4) At the end of the year, the payer calculates its actual cost of providing care for the patient population. (This includes the costs of care furnished by providers not included in the CIN. Patients in the assigned population are not limited to providers in the CIN).
(5) If the actual costs of care are less than the benchmark and if specified quality measures are met, the CIN will receive a portion of the savings. If those measures are not met, the payer will not share the savings with the CIN.
(6) Under "two-sided" shared savings programs, the CIN is liable for a portion of the difference if the actual costs of care exceed the benchmark.
(7) The CIN is responsible for deciding how the shared savings (or losses) are to be distributed among its members. Typically, a portion of any shared savings payment is retained by the CIN to pay its expenses.
11. What is driving interest in forming a CIN in our community?
Providers in other Florida communities are forming clinically integrated networks. These include Bay Care Physician Partners in Tampa Bay and Holy Cross Physician Partners in Ft. Lauderdale. Payers and employers in the St. Augustine area have approached Flagler Hospital and other community providers regarding network contracts with pay-for-performance incentives and possibly participation in a shared savings program.
Some payers are looking to "centers of excellence" as exclusive providers for certain elective procedures within a region. Forming a CIN to achieve higher quality and greater efficiency may discourage payers from contracting with providers outside our community. Further, CMS' transition to value-based purchasing for hospitals and physicians is leading the way to greater transparency in health care. Providers are being "scored" on their effectiveness. Regardless of whether that initiative has merit, more consumers will come to rely in these "scores" in selecting health care providers. Through a CIN, providers can collaborate to improve overall scores on key quality measures.
12. Is now really the right time to pursue this? Shouldn't we take a "wait and see" approach?
Experts agree the next three years will be a period of rapid change in health care, as meaningful payment and delivery system reforms take hold. Provider communities have three choices – make things happen, wonder what happened, or have things happen to them. If the community waits too long, it will lose all opportunity to shape its own destiny.
13. Are there CINs in other communities that we can use as models for our network?
There is much to be learned from providers in other communities that have formed CINs. Concise summaries of several operating CINs (i.e., currently contracting with payers) will be made available to help you envision what form our community's organization might take. Also, you will have a chance to speak with other CINs' physician leaders regarding their lessons learned. One consistent theme you will hear is the need for the initiative to be physician-driven. Keep in mind, however, there are only a handful of CINs that have been operating for an extended period of time. Most CINs have commenced operations only recently. There are far more communities (like ours) still in the planning process. There is no "one size fits all" solution for clinical integration. To be successful, our CIN must fit within our community's culture and values. Thus, it is critical all providers have the opportunity to participate in this planning process.
14. Have other CINs been successful in improving quality and efficiency in health care delivery while protecting physician incomes?
Early adopters have achieved impressive results. For example, you can find success stories at Advocate Health Care in Chicago, Billings Clinic in Montana, and Mesa IPA in Grand Junction, Colorado. Advocate Health Care publishes an annual Value Report (available at
http://www.advocatehealth.com/2012valuereport), which clearly demonstrates the value of a high functioning CIN to providers, payers, and patients.
15. What types of protocols have other CINs adopted?
Typically, a CIN develops its initial set of protocols around delivery of preventive care and management of patients with chronic diseases (e.g., diabetes, COPD, asthma, heart failure). CINs have utilized well-recognized quality standards as a basis for protocol development including, for example, National Quality Forum-endorsed standards. Other sources include CMS' Physician Quality Reporting System measures, the Medicare Shared Savings Program performance standards, and Stage 1 and 2 meaningful use quality reporting requirements.
To view an example of CIN-developed protocols, please visit the website for Integris Health Partners,a CIN in Oklahoma City. The web address is http://integrisok.com/health-partners/metrics.
16. How do CINs generate cost savings?
First, adherence to CIN-approved clinical protocols and sharing of patient data eliminates unnecessary and duplicative care. A greater emphasis on preventive services saves money by avoiding more expensive care down the line.
Second, a physician participating in a CIN has access to the network's care coordination services for his or her patients. This includes transitional care management as well as patient navigator programs.
A transitional care management program focuses on patients discharged from institutional care (hospital, skilled nursing facility) to ensure they successfully transition back into their home setting. These programs have proven successful in reducing hospital readmissions and costly emergency room visits.
A patient navigator program focuses on a small number of high risk, high cost patients. Research indicates that in most communities, five percent of the patients generate fifty percent of the cost. By aggressively supporting these patients through care coordination and treatment regime adherence, patient navigators often can reduce these costs by one-third.
17. What role does technology play in a CIN?
A CIN can employ technological solutions in several ways to advance its goal of improved population health:
First, technology can assist a physician in adhering to clinical protocols, such as tracking whether a patient has received certain preventive services.
Second, reporting on quality measures to the CIN (or to payers directly) may be accomplished using IT solutions.
Third, data analytics can identify those patients for whom certain interventions are appropriate, thus allowing providers to manage those patients more effectively.
Fourth, technology can assist the CIN in tracking care costs to identify opportunities for improvement.
Fifth, electronic health information exchange permits CIN members to effectively coordinate patient care (especially for high-cost, high-risk patients), thus improving outcomes and reducing costs.
Sixth, patient and family member access to electronic records enables them to be more active and engaged participants in the care process.
18. How will the CIN make decisions? How will the interests of the hospital balance against those of the physicians?
These are critical questions to be addressed through the planning process. The CIN's governance structure must further its members' common goals while protecting their individual interests. This is achieved through the selection of governing board members, balancing voting rights among participants, reserving certain fundamental decisions to the respective parties, delegating organizational functions through carefully drafted committee charters, and other organizational processes.
The consultants are developing different governance models for consideration. Before deciding on a particular structure, however, there should be consensus around common goals, i.e., identification of the functions the CIN will perform. Stated another way, the
form the CIN takes should follow from the
functions it will perform, not vice versa.
19. What services will the CIN provide to its physician members?
Again, one of the key tasks for this planning phase is to reach consensus regarding the range of services to be provided by the CIN. The following is a non-exclusive list of services a CIN might provide for its members.
Keep in mind the CIN does not necessarily have to provide all services directly; the CIN may contract with third parties (including, for example, the hospital) for specific services. Also, in the future, the CIN may contract to provide services to third parties. This may be a way for the CIN to generate revenue to support its operations.
(1) Operate disease registries/data analytics
(2) Implement evidence-based medicine practices/population health improvement strategies
(a) Identify and develop practice protocols (e.g., align with payer-required measures)
(b) Support protocol implementation and adherence (e.g., education, technology solutions)
(c) Monitor protocol compliance (reporting on quality measures)
(d) Implement corrective action for protocol non-compliance
(3) Establish chronic disease management/patient navigator program
(4) Develop transitional care management program (based on new Medicare Physician Fee
Schedule payment for post-discharge transitional care management)
(5) Implement medication therapy management program
(6) Provide Physician Quality Reporting System support for physician members (e.g. education, abstracting, technology solutions)
(7) Provide CMS Maintenance of Certification program support for physician members (e.g, CME opportunities, practice assessment, attestations)
(8) Develop patient education and engagement strategies and tools (e.g., shared decision-making)
(9) Explore clinical co-management arrangements and/or gain-sharing opportunities (hospital service line quality and efficiency improvement programs with financial rewards to physicians if program meets specified targets)
(10) Develop bundled payments for specific episodes of care (e.g., surgical procedures, maternity)
(11) Develop Centers of Excellence (by service line)
(12) Participate in Medicare Shared Savings Program (accountable care organization)
(13) Pursue preferred network contracts with private payers
(14) Pursue shared savings and/or global budget contracts with private payers (including employers)
(15) Develop and market health plan (e.g., hospital employee health plan, Medicare
(16) Provide EHR/meaningful use technical support for physician members
(17) Furnish support for primary care providers in implementing patient-centered medical home model
(18) Form or contract with group purchasing organization
(19) Perform back-office functions for physician offices (e.g., coding, billing, collecting, accounts payable)
(20) Provide support for ICD-10 transition and compliance
(21) Provide HIPAA Privacy and Security Rule compliance support
20. How will the CIN's operations be funded?
Exploring funding sources will be part of the decision-making process for identifying the specific functions the CIN will perform. Other CINs fund their operations in a number of different ways including, for example, contributions from the participating hospital, physician dues, the sale of investment interests, revenue generated by selling services, and withholdings from payer reimbursement and/or pay-for-performance payments.
21. Will CIN participation be open to all medical staff members?
To ensure compliance with the antitrust laws, CIN participation should be open to any physician who satisfies established minimum requirements for membership and who maintains compliance with specified performance standards. Again, the planning process involves identifying reasonable and appropriate requirements and standards.
22. How will I join the CIN? What will be expected of me as a CIN member?
Again, this is a matter to be addressed through our planning process. For other CINs, the usual process has been for the governing body to develop a network participation agreement which specifies the rights and duties of CIN members. Community providers are given the opportunity to review this agreement prior to making a formal commitment to CIN participation. At a minimum, a physician member of the CIN will be expected to adhere to CIN-approved protocols and otherwise participate in and support CIN operations. Depending on decisions made by the CIN's governing body, a participant's ability to contract with payers independently or through another network may be subject to restrictions.
Participation in the CIN will be completely voluntary. A physician's decision regarding participation will not impact his or her status as a member of the hospital's medical staff.
23. What will happen to my private practice if I join the CIN? New 02/25/13
The purpose of a CIN is to create an infrastructure through which independent providers can work together to improve the quality and efficiency of care. A physician participating in a CIN will continue to bill and collect for services under his or her existing payer and will remain responsible for his or her practice's operations.
Neither the CIN nor the hospital will purchase any physician practice. No physician will be employed by or have an independent contractor arrangement with the CIN or the hospital as part of CIN participation. Other than claims data, participating physicians will not be required to share financial information with the CIN or the hospital.
A physician's relationship with the CIN is defined by the terms of the participation agreement. A physician cannot be required by the CIN to do anything that is not specified in that agreement. Nor can the CIN take any action against a physician that is not spelled out in that document.
If the CIN enters into a shared savings contract, the payer (Medicare or a private insurance company) will make a single lump sum payment to the CIN representing its share of the savings. The CIN then will distribute that money to its participants based on a pre-determined formula defined by the CIN's governing body. A portion of the shared savings may be retained by the CIN to cover its operational costs.
As discussed above, a CIN may offer "back office" services to support its physician members, such as billing, coding, collections, and compliance. A physician participating in the CIN, however, will not be required to purchase or otherwise accept those services.
24. What will happen to CIN participants who do not meet established standards?
The implementation of clinical protocols and performance measures will be an ongoing process of education and continuous quality improvement. No provider will be expected to perform at a certain level without adequate support to achieve that goal.
While the intent is to improve quality and outcome metrics, successful CINs demonstrate the will to cull an outlier if all attempts, such as peer review and education, fail. To protect individual's rights, the CIN may establish a review process to afford a physician the opportunity to challenge an adverse decision. No participant will be excluded based solely on subjective criteria.
25. I still have other questions. Who can answer them?
You may also contact Keith Justice via email at email@example.com or Jason Barrett at