Rationale and Requirements for Clinical Integration

Well before the passage of the Affordable Care Act in 2010, providers have been joining together in an effort to better manage the care of a specific patient population by setting up a clinically integrated network, or CIN. 

Clinical integration is defined by an active and ongoing program to evaluate and modify the practice patterns of physicians and create a high degree of interdependence and cooperation to control costs and ensure quality. The goal is to create a meaningful prospect of improving efficiency in the delivery of care, reducing costs, better managing utilization, or improving the quality of care.  

Historically, the U.S. Department of Justice (DOJ) and Federal Trade Commission (FTC) had used antitrust law to prevent private business practices that unreasonable restrain competition and to ensure that consumers benefitted from lower prices, better quality and increased choice, selection, convenience or innovation when competitors collaborated with each other. In Arizona v. Maricopa County Medical Society (1982), the Supreme Court made it clear that physicians in independent practices are supposed to compete. They further noted that when physicians do not compete, by collectively setting the prices at which they sell their individual services, they can be guilty of illegal price fixing. For a CIN, even if there is some integration, any agreement on price must be “reasonably necessary” to realize efficiency goals.

Through the 1990s and early 2000s, both the FTC and DOJ provided guidance, including statements of antitrust enforcement policy in healthcare and advisory opinion letters, which outlined the requirements CINs must establish through their governance, participation agreements and operations. 

Accordingly, CINs form their operating by-laws and participation agreements with providers to create a contractual arrangement that governs practitioners’ participation in the CIN. CINs can include hospital systems, groups of employed practitioners, independent local practitioners, existing ACOs or any combination thereof.  

To be in compliance, a CIN must demonstrate the following four characteristics:

1. Physician leadership: A CIN must have physician leadership integrated into its governance. Practically this means appointing either independent or employed physicians to the board of directors and to key committees responsible for overseeing the operations of the CIN.
2. Clinical guidelines: Outlined in the participation agreement are requirements to which providers must commit for complying with clinical guidelines and working on performance improvement initiatives.
3. Sharing relevant patient data: To provide more coordinated care and create visibility across the network, CINs put in place data sharing solutions to give participating practices a comprehensive view of care provided to patients by all providers. The plethora of solutions developed to accomplish this requirement reflect the diversity of provider networks themselves and may incorporate data warehouses, data exchange, population health management and cost and quality reporting capabilities.
4. Measurement and performance monitoring: CINs must demonstrate they are improving value. Data analytics are employed to measure provider adherence to clinical guidelines, to track the achievement or gaps in achieving measures related to quality, the cost of care and efficient utilization of resources. Further, CINs must be able to identify non-compliance or under-performance and institute a mechanism to remove providers from the CIN.

As providers reflect on the impact the COVID-19 pandemic has had on practice revenues, those who are not members in a CIN may consider the potential benefits of participation. By collaborating with peers in their practice community, physicians in independent practice can remain independent, avoiding direct employment by a hospital network while taking advantage of the infrastructure, shared risk and structured approach to achieving the Institute for Health Improvement’s Triple Aim™.  

Clinical integration allows providers to demonstrate their quality to patients, pursue enhanced revenue through better management of chronic patients and engage in joint efforts to develop the necessary programs, technology and human resources which may be unaffordable for a solo practice. In a year with considerable volatility effecting ambulatory practice, CIN participation may help practices stabilize their revenue through alternative payment models, thus becoming more sustainable for the long term.

For more information or help with implementing clinically integrated networks, please contact the NextGen Advisors at: advisors@nextgen.com