As healthcare shifts from fee-for-service to value-based reimbursement, physicians are facing both complex new requirements and exciting opportunities. Many are finding strength in numbers — forming clinically integrated networks (CINs) to best address these changes.
When structured properly, CINs enable doctors to improve quality, reduce healthcare costs, and earn significant financial rewards. The same can be said for accountable care organizations (ACOs), which are CINs designed specifically for Medicare.
Just as with a sports club, decisions regarding team members should be based on statistics. Such provider data is available from the Centers for Medicare and Medicaid Services (CMS), in the form of claims information. For instance, CMScan supply each of its participating provider’s:
For a more detailed list of the Five Common CIN Pitfalls, download now or at the end of this blog.
Of course, it’s important to adjust for external variables, like patient demographics and diagnoses. At Continuum, we set benchmarks* that incorporate such “risk-adjustment” factors, to ensure apples-to-apples comparisons of prospective CIN members. (The CMS data are relevant across payers, as providers’ care decisions are typically not affected by type of insurance.)
Another caveat: Don’t automatically exclude providers who fall short of benchmarks; they may simply need to make some changes to reach the target. By drilling down further into the data, we often uncover simple opportunities for improvement. For example, if a doctor refers patients to a high-priced laboratory or specialist, we identify and may recommend more cost-effective alternatives.
We consider other factors, too: Does the provider use an electronic health record (EHR)? Do they have systems that support value-based care delivery? Are they ordering procedures that are redundant or medically unnecessary? If they’re not willing to change to a value-based mindset, they will negatively impact the success of the CIN and all its members.
Ultimately, the point is to be part of a high-performing team. So choose your teammates wisely through an objective, data-driven approach. A skilled partner, such as Continuum Health Alliance, can provide the sophisticated prequalification services necessary to drive success.
For more tips on building a successful CIN, download our article on Five Common CIN Pitfalls.
*Continuum bases these benchmarks on national standards of Clinical Classification Software (CCS) of the Agency for Healthcare Research and Quality (AHRQ) and the Health Data Consortium (HDC).