(PART ONE IN A THREE-PART SERIES ON CLINICAL INTEGRATION)
Physicians the Driving Force behind CIN Success
With new pressures incurred by the Affordable Care Act and the increasing movement of the US population into Medicare and Medicaid, physicians and hospitals are aligning in different ways in order to take advantage of Shared Savings Programs and other value-based and clinical risk arrangement payment models.
These associations, called Clinically Integrated Networks (CINs) are groupings of health care providers and facilities that (in theory) work together collaboratively to provide high-quality, cost-effective healthcare to a specific population of patients.1 However, not all CINs are aligned for success or truly clinically integrated. Because physicians are responsible for driving the clinical care of patients, the move to lower overall cost and improved quality accountability needs to start with them.
Quality Care and Clinical Value: Starts with physicians and ends with integration
Historically, physicians trained to work and make decisions autonomously are rewarded for individual achievement. Their value as physicians––as well as their sense of self––was built upon their ability to be the best in their area of specialty.2 This tradition, as well as the Fee-For-Service payment structure, resulted in competition rather than collaboration at its foundation. However, taking advantage of value-based payment opportunities cannot be accomplished working in isolation from integrated systems of care, and requires attention and resources to achieve positive outcomes for entire populations.
In order to successfully deliver cost-effective quality care, physicians need to work together towards shared clinical goals, regardless of whether they are hospital employees (e.g. Physician Hospital Organization) or tightly managed independent practice associations (IPAs) or group practices. Physicians in an atmosphere of trust and transparency must agree to proven protocols and value-based metrics, and this is often best served by forming a physician-led clinically integrated entity that includes participation criteria. Creating an integration structure helps providers align to take on the higher levels of accountability needed to create a successful CIN.
The advantage of legal integration
In 1996, the Department of Justice and the Federal Trade Commission set up a definition of clinical integration to allow physicians and health systems to collaborate without fear of antitrust violations.1 In return for setting up a physician-led professionally managed network, specifically defined as having “an active and ongoing program to evaluate and modify practice patterns” while creating a “high degree of interdependence and cooperation…to control costs and ensure quality”, legal entities are allowed to directly contract with large employers, private insurers and other payors for increased reimbursement rates and pay-for-performance rewards.1 However, to meet these requirements, network members, both physicians and hospitals, need to invest in processes and systems for enhanced communications, and services themselves must be coordinated toward a value-based result.1 That means physicians must be engaged and assume leadership roles in healthcare organizations.
Integrated governance and the need for physician leadersBecause many important decisions will require the “buy-in” of different stakeholders, it is important to foster the participation of a representative sample of network members in governance and leadership roles—including employed and independent physicians, primary care physicians, and specialty physicians, hospital executives, and other participating entities, if any. Physicians, used to making independent clinical decisions, may have the temptation to operate at “arm’s length” from the rest of the health system partners, but there is no room for siloed thinking in an integrated network --enter the need for physician leaders.2
Physicians who have been in private or group practices may be accustomed to running a small business and managing its resources. However, these skills are very different from those needed to lead delivery system change. According to physician leaders from three major integrated healthcare delivery systems, the key factor that sets a leader apart from a manager is the ability to create a vision for the future. Physician leaders must consider how to align all network providers to shape a healthcare delivery system that serves the physical, social, psychological, and financial needs of many patients, rather than individuals. The right leader can inspire physicians to change by helping them gain a clear understanding of why things must change.2
Clinical risk arrangment payment models of many types allow IPAs and health systems to invest in leadership development as a strategic priority, and rewarding leadership and skill in group dynamics, as well as rewarding individual competence, may be key to successfully integrating for accountability.1
The bottom line
Medical groups, IPAs and health systems willing to pursue a CIN must empower physician leaders to have an influence on the future direction of the CIN. This will help to integrate the physician's clinical expertise into CIN operations and increase cooperation and credibility among the participants. Furthermore, dedicated physician and administrative leadership will be required to successfully implement a major change project of this magnitude.2
Check back next week for Part Two in this series: CIN Participation Qualification and Quality Performance Criteria
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1. Becker Hospital Review. The 7 components of a Clinical Integration Network. Oct 19, 2012. Modified to reflect Continuum’s model for a CIN.
2. Cochran J, Kaplan GS, Nesse RE. Physician leadership in changing times. Healthcare 2 (2014) 19-21.