Are CINs the Newest Cure?

Leaders in the hospital field are already pursuing integration to improve patient outcomes and reduce the ballooning cost of health care. The Centers of Medicare and Medicaid Services' quality initiatives, and now the Affordable Care Act, demand a new health care model that brings hospitals and physicians together to coordinate the continuum of care for improved patient care. One emerging trend to enhance care coordination is clinically integrated networks, or CIN.

The components needed to successfully implement a CIN have been well documented over the last two years, and include:       

• Centralized information technology infrastructure
• Quality data strategy and assessment process, including meaningful metrics
• Physician-run governance

Doctors and Data are the Key

Recently, I had the opportunity to hear an executive director and a hospital CEO of an up-and-coming CIN speak about why hospitals and physicians are partnering in this manner over other models like mergers, acquisitions or employment arrangements.       

• From the hospital CEO's perspective, a CIN is a more cost-effective way to increase market share over acquiring private practices. Simply put, the hospital just doesn't have enough cash to continue buying practices and to support the increasing fixed costs associated with running more offices.
• For physicians, participating in this newly formed CIN provides a way to decrease expenses while maintaining autonomy through governance of the network.
• The payor working with this particular CIN benefited from the collaboration within the network which led to cost savings that are shared with the CIN.
• Ultimately, the patient benefits from physician alignment resulting in better coordinated treatment and improved health.

When the speakers were asked why clinically integrated networks, generally, hadn't been successful prior to Health Care Reform, the answer was mistrust. Doctors didn't trust hospital administrators, and administrators suspected doctors would not stay engaged or incentivized.

To overcome this hurdle, emphasis must be placed on creating a culture of trust and transparency, and empowering physicians to take ownership through leadership positions. Encouraging physician leaders to influence the direction of the network will increase cooperation and build trust.

Physician governance dictates that the physicians must hold themselves, and one another, accountable for conformity to the defined protocols. Assigning physician leaders the responsibility of defining appropriate metrics and using shared data to monitor performance is key to physician engagement and, ultimately, a successful CIN.

One practice is to form quality committees that monitor performance against physician-defined, predetermined quality metrics. If the committee finds a physician is not following guidelines or failing to meet necessary metrics, they will meet with him or her to attempt to rectify the problem. If performance continues to be an issue, the physician may find they will lose shared savings, miss out on referrals, or possibly not be allowed to continue as a member of the network. 

Furthermore, employing a comprehensive communication strategy with clear objectives combined with adoption of data sharing mechanisms is imperative to attaining buy-in and building trust among all CIN stakeholders. Include in this strategy how physicians and non-physicians outside leadership positions can provide feedback to CIN leadership about operations, quality and metrics, and the steps leadership will take to evaluate and act on appropriate feedback. Most importantly, keep all stakeholders apprised of the feedback received, and the actions leadership took to improve the CIN based on stakeholder feedback.

While CMS quality initiatives and ACA push care models to adopt more robust IT infrastructures, creating a culture of trust and transparency takes commitment and time. With thorough physician involvement in leadership positions, meaningful metrics and peer reviews, as well as a robust, consistent internal communications strategy, a new CIN may grow and thrive in today's evolving healthcare landscape.