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Clinically Integrated Networks or the acronym, CINs, are quality focused organizations that negotiate with payers to provide potential additional payments to providers based on established criteria. This criteria is usually a shared savings based criteria or a HEDIS-based quality improvement metric. A CIN can be one Health System or a Health System and independent practices that contract together. The CIN needs to maintain patient clinical data created either by the group being on one common linked electronic health system or each entity/Medical practice sharing data to a CIN managed population health management tool. The integration team at Physician Xpress, Inc. has connected pediatric practices to multiple CINs to share data appropriately so the pediatric practice can meet the data requirement for participating in the CIN. This data connection usually entails sending a patient roster and a routine (daily or weekly) clinical data of patients seen by providers at the practice (sent via a CCDA patient data file).
While CINs are an option for many pediatric practices, practices should evaluate if the benefits of joining a CIN are higher than the cost/administrative work and/or loss of opportunity to engage in a focused quality contract (if a large pediatric group for a regional payer). This article provides some additional background on CINs to help pediatric practice owners and/or practice administrators when considering contracting with a CIN.
Let’s first look at how CINs make money….
Always “follow the money” to understand how an entity operates and their motivation to make money. If your practice is considering working with a CIN, it is worth the time and effort for your pediatric practice to understand how the CIN makes money and if there is potential alignment with the pediatric practice.
CINs can be focused in one area (e.g. primary care) or multi-specialty and the organization can be for profit or not for profit. The organization can be an independent company, part of a Health System or even part of a medical society. How a CIN is organized is a factor to consider in the motivation of the owner. Let’s look a little closer at motivation by organization type.
Not-For Profit Hospital/Health System:
A Not-for Profit Hospital/health system might form a clinically integrated network (CIN) with providers within the Health System and independent community medical practices to identify methods and approaches to migrate to a new payment model discussed nationally (e.g. Medicare shared savings) as well as to enhance provider referral and collaboration. A positive of this structure, from the perspective of a private pediatric practice, is usually the CIN is well structured, has robust IT infrastructure, professional full-time staff, and appropriate audit systems to review and distribute the funds (e.g. independent physicians on the contract and finance/audit committees to verify appropriate distribution of funds and management of the CIN). Additionally, if the CIN is multi-specialty with a large number of providers (over 200), the CIN has leverage to negotiate agreements that can only be feasible with a large number of providers. The negative is that the CIN might use the data for either seeking to identify practices to purchase or areas to expand their own network or have high operating costs that reduce the total percentages passed through to independent practices. Additionally, if the CIN is owned by a Health system, the CIN has an incentive to develop contracting approaches that favor the Health Systems Medical groups/practices. This incentive for their own groups might or might not be aligned to the goals of your organization.
Medical Society:
A Medical Society (like PA Medical Society) can start a CIN with a certain motivation. In the case of PA medical society, the motivation is an extra incentive for independent Primary Care Physicians to stay independent as well as to provide higher transparency on how CINs operate. A Medical Society is an entity that is mission driven to support physicians. Their focus is usually how to best serve the physicians in the community. While Medical Societies have great missions and intent, the organizations can become potentially have high cost structures if they are in the early phase of establishing a CIN. A Medical society is usually “new” to contracting with Payers, managing IT infrastructure and management of systems. Additionally, while most Medical societies are very strong in the area of policy they might be thin on experience in the area of operating a medical practice or Health system.
For profit CIN:
A group might form a corporation that is a CIN. The group would decide if the corporation based CIN is focused in primary care (e.g. Pediatrics) or multispecialty. A positive of this structure is that the group is usually entrepreneurial with low cost structure. This could lead to higher sharing of revenues with the individuals of the CIN. A negative of this structure is that the entity might start with good intentions but later migrate to optimize their owners or sell the entity to a payer or other organization so the new entity can ‘keep’ as much money in the middle. A challenge for a new CIN is that the CIN might not have enough members or lives to interest additional contracting from a payer. A smaller group might not have appropriate financial and contracting controls and oversight. This lack of oversight can have two issues: not enough direction to medical practices in the opportunities to enhance performance and lack of appropriate financial auditing (leaves the CIN open to take more money without the members knowing).
No matter how the CIN is structured, the approach to making money is usually in one of three areas:
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Obtain a “Coordination of Care” agreement with the payer that pays the CIN a certain amount of dollars per year for clinical care coordination.
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Obtain a shared savings agreement that identifies the share savings with all providers in the CIN if the total cost of care for all providers is below a certain threshold.
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Obtain a quality based agreement that pays a certain amount for achieving outcomes.
The CIN usually keeps the revenue from item 1. (coordination of care payment) and passes on some of the shared savings (item 2.) and/or quality based incentives (item 3.). Since there is one large pool of money from employers to pay for health care, the CIN can be viewed as an entity in the middle that adds extra cost if the payer does not see the value. Sometimes the CIN is successful with regional/smaller payers on a targeted program. Payers are trying to identify arrangements in quality and/or shared savings that can bend the cost curve. There is opportunity for CINs to make some money over their costs but most operate at a small loss.
Let’s next look at how CINs contract with Managed Care Payers and Providers….
The CINs have an agreement with many practices as well as with payers. This contracting is the real potential value to independent practices. The CIN structure usually allows for some opportunities for small practice that they would have with select payers. Contracts include: Care Coordination, Shared Savings, Quality outcomes based on HEDIS parameters (Clinical Quality Measures).
Care Coordination:
Care Coordination is usually a set dollar amount the CIN receives per member per year for coordination of care. This money is usually not passed through and used by the CIN to pay for the infrastructure costs such as IT systems, software, analysts, contracting costs and other costs of the CIN. The more lives the CIN has within the network, the more money the CIN receives for Care Coordination. CINs might not actively disclose the amount they receive in Care Coordination. If they do not, it is reasonable for a practice owner to ask the amount the CIN receives for Care coordination for which payers and how much per patient.
Shared Savings:
The opportunity from a payer and employer perspective for the CIN is to bend the cost curve via a shared savings program. How this works is that the payer identifies the estimated cost of care for all services within the CIN. The payer and the CIN negotiate a shared savings agreement usually based on a cost of care projected vs. actual for all the patients within the CIN. If the cost is below the projected cost, the CIN shares in the revenue savings via a check paid to the CIN for the shared savings per the agreement. The CIN identifies with the payer high cost care and items (e.g. Specialty Pharmacy) and works with the members in the CIN to optimize treatment with cost effective care. While all medical groups can help with the savings, certain specialities with high cost patients can contribute the most of this savings. The CIN might share the shared savings revenue on a provider or physician basis and a keep a percentage for the CIN for operation (goal would be for the CIN to keep 30% or less but many retain up to 50% of the revenue).
Quality/Outcomes Based on HEDIS Parameters (Clinical Quality Measures):
Payers are concerned about star ratings and other ratings that align to HEDIS metrics. These ratings help a payer attract employers, government agencies and other groups that are their customer focus. Due to a CIN needing to maintain clinical data across all medical practices, the CIN can work with the payer to develop a quality/outcomes based contract based on quality parameters. Many of the HEDIS parameters are adult-based measures. The measures that are Pediatric based include: % of patients that received at least six well visits prior to being 18 months of age, % of patients over two years of age that have an annual well visit, immunizations for Adolescent (HPV, TDAP, meningococcal) and Pediatrics Immunizations (MMR, varicella, DTaP, IPV, HepB ). Note that the PediatricXpress system provides practices a list of patients that are due to well visits and immunizations in the tools section. These tools in the PediatricXpress system is a great resource for practice staff to leverage so they can optimized the performance of the Clinical Quality Measures linked to the Quality/Outcomes based agreements.
Let’s consider some key questions to ask and monitor…
Like any contracting opportunity, evaluate each CIN with great care to ensure that opportunity and potential aligns to your pediatric group. If your pediatric practice receives the majority of revenue from 2-3 payers, the CIN might not be the best option depending on the number of patients and the CIN work versus return. Additionally, once your pediatric practice makes a decision to join a CIN, evaluate the contract (insure can terminate as needed or within 60 days) and monitor/oversight.
Some key questions to consider on evaluating and/or monitoring an agreement with a CIN include:
Which payers does your CIN have agreements with?
What are the Pediatric measures/incentives on these agreements?
Which counties in my state are these contracts aligned to?
What is the average payout (if any per Pediatrician/provider)?
How often is the measurement period (quarterly, 2x/year or annually)?
What data requirements for the CIN?
What % of the TOTAL payments are redistributed to the Practices?
Describe the reporting and auditing function that allows practices to view the total $ received and payments made.
What are the contract terms and termination clauses?
A practice leader or owner needs to trust but verify for the data, reporting and payments by the CIN. How much of the money is the CIN keeping in total? If the checks are small and too much is going to the CIN for the monitoring, follow-up and work, consider separating from the CIN.
Summary:
There is much pressure from payers and employers to reduce health care costs. Payers contract with many Clinically Integrated Networks (CIN) to either enhance their quality scores and/or to reduce costs. CINs are an approach that some independent medical practices can participate in to potentially obtain an opportunity. Each pediatric practice should carefully evaluate if they should participate in a particular CIN, understand the contract and administrative requirements, potential payouts and audit functions.
