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    As the healthcare industry is focused on controlling costs, improving quality of care and growing reimbursement, clinically integrated networks (CINs) offer a framework for approaching these goals.

    But as the ambulatory care environment shifts from fee-for-service (FFS) to value-based care, what clinical integration looks like — and what is expected of providers — requires some updating.

    How traditional clinical integration is changing

    Defined by the Department of Justice (DOJ) in 1996, clinical integration is “an active and ongoing program to evaluate and modify the practice patterns of a physician network’s participants in order to create a high degree of interdependence and cooperation among the physician members.”1

    Josh Berlin, JD, chief executive officer, rule of three LLC, and advisory board member, Validation Institute, noted at the 2020 Medical Practice Excellence Conference that the DOJ definition can be broken into four major pillars:

    1. Evidence-based clinical protocols
    2. Care review based on those protocols
    3. Mechanisms to ensure adherence to those protocols
    4. Technology implemented to enable interoperable patient data.

    David Carmouche, MD, president, Ochsner Health Network, and senior vice president, Ochsner Health, leads CIN activities across Louisiana for Ochsner and sees the reality of clinical integration changing. “The goalposts have moved on this,” Carmouche said.

    While the CIN model makes sense in terms of investing for an improved product and higher reimbursement, “I just don’t think it’s played out that way,” Carmouche added. “Healthcare costs continue to go up, and I think the solution has really become asking providers to take more financial risk, to actually have their pay tied to the outcomes of the patients they serve, and really make them responsible or encourage them to be responsible for the overall cost of care in this country.”

    Key elements

    A McKinsey & Company report points to five key elements for CINs:

    1. Physician responsibility: Physicians “cannot be passive members” and should actively participate via serving on committees, adhering to clinical protocols, etc.
    2. Physician investment: Spending actual money (toward IT or other needed elements) or just time will make a big difference.
    3. Physician accountability: Noncompliance with care protocols and failure to meet quality measures needs to be dealt with via a mechanism to discipline or exclude those physicians.
    4. Outcome measurements: Clinical metrics or benchmarks must be available and shared.
    5. Non-exclusivity: Due to antitrust risks, physicians who join a CIN “generally should be permitted to contract independently with payers.”


    Source: Kumar P, Levine E. “Clinically integrated networks: Can they create value?” McKinsey & Company. June 2016. Available from: mck.co/3qMNHsg.

    Another element of the CIN model is cooperation, which can be tricky to navigate when bringing independent physicians together. As Juan Espinoza, MD, co-founder of the Independent Pediatric Collaborative of Long Island (IPCLI), noted in Medical Economics, “[w]hat we’re doing is starting to see each other as collaborators, instead of competitors.”2

    While that sounds familiar to those who have moved into value-based arrangements, the reality is that the clinical integration needed to produce those results “is much more complicated” than initially envisioned, Carmouche said.

    As Berlin notes, issues contributing to increased complexity include:

    • Patient access to visits
    • Lack of interoperable information, often due to paper-based charts or siloed electronic systems
    • Lack of alignment between provider incentives and patient outcomes
    • Lack of communication across the care continuum
    • Out-of-control cost increases.


    Carmouche added that variation in provider approaches to care and the associated variation in cost and outcomes is also a hurdle facing the industry, as the problem is keenly felt by patients. “From a consumer’s standpoint, this is totally not transparent,” Carmouche said.

    Handling new risk and consumer pressures

    To manage these new complexities, Berlin pointed to two primary goals for providers in CINs: Increasing the level of quality care while lowering the cost of healthcare.

    In terms of cost, Berlin said that many practices have “retreat[ed] back to traditional healthcare and a more volume-driven environment,” especially during the COVID-19 pandemic. But the pressure from the federal government to move payment into more value-based arrangements — including shared savings, bundled payments, shared risk and full capitation — is likely to continue as the population continues to age into Medicare and it remains difficult to sustain financially at Medicare FFS rates as commercial payments shrink relative to the growth of Medicare, Carmouche added.

    “It’s not going to go away, it’s probably going to accelerate,” Carmouche said, underscoring the need to find the right mix of value-based payment in Medicare to bring reimbursement up, “regardless of what the commercial payers do.”

    The ways in which the industry has responded to reimbursement stagnation in recent years involved a rise in private equity consolidation, creation of managed services organizations (MSOs), increased implementation of technology and rising patient consumerism in making choices about where to receive care, Berlin noted.

    “This is just people looking at healthcare like they look at every other part of their life,” Carmouche said. “Patients and consumers are increasingly willing to put convenience over a historical brand relationship. … For those of us who are in traditional healthcare delivery settings, we’ve got to learn this game.”

    For those in brick-and-mortar care facilities, that often means extending the care model into virtual care delivery, as well as going beyond traditional hours of operation. In the Ochsner system, Carmouche said it evolved into 24/7 telehealth capabilities, integrated urgent care and more digital health platforms.

    “What we’ve had to do at Ochsner over the last few years is figure out, how do we stave off the retail entrants into healthcare who are looking to disrupt us,” Carmouche said. “We can’t do it assuming that we’ve been [patients’] trusted source of care for the last 20 years and that they’ll continue to show up.”



    Watching for “juggernaut” organizations such as Walmart entering the healthcare delivery space is especially important and serves as impetus to explore improving clinical integration, Berlin said. “More than 90% of the country lives within 10 square miles of a Walmart,” Berlin added, underscoring the proliferation of potential competition for traditional physician practices.

    The Walmart health center model also already has an advantage over some traditional clinics in the ability to offer a simple rate card for primary care services, tests, counseling and dental services. “Walmart knows the consumer and knows the value of cost transparency to their consumers. … Most people who come into our offices — they may know they have a copay, but they’re not sure what they’re going to [pay] downstream for the MRI that got ordered in the lab,” Carmouche said.

    Envisioning the future of clinical integration

    At the core of what Carmouche and Berlin envision as “clinical integration 2.0” is a strong emphasis on population health. “A [CIN] really increases its value proposition significantly by focusing more on patients,” Berlin said, with primary care at the core of that effort.

    Though most of Ochsner’s 1,500 physicians are not in primary care, Carmouche said the system views primary care as the source of creating value going forward. “You don’t get the privilege of taking care of someone later, when they need heart surgery or a knee replacement, if you don’t have a relationship with them and you can’t refer them to you,” Carmouche said.

    The “transformed primary care” model, Carmouche added, is led by a physician and usually has:

    • A nurse practitioner (NP) or physician assistant (PA)
    • An integrated behavioral health resource
    • Access to pharmacy support
    • Care coordination.


    Though that larger care team incurs higher costs, “the cost becomes margin generation in capitation or risk-based contracts,” Carmouche noted. The improved population management should then lead to downstream benefits of better relationships that “reward subspecialist hospitals [and] post-acute providers” with patient volume.

    The post-acute care space, Carmouche said, is especially vital, as variation in cost is high. “We’ve had to go out and build our own integrated network of providers who want to share data with us, who are making commitments to not send everybody with a fever back to the hospital to be readmitted,” Carmouche said. “What we want our hospitals to do is just get really good outcomes: Be safe, be effective, and help us coordinate the flow of patients out of the hospital to make sure they get home or to post-acute with the right coordination, and then help us keep them out of the hospital if they don’t need to be there.”

    All of this work in keeping track of patients can lead to expansion of home health services, since more patients are seeking care where it’s convenient. “[COVID-19] has certainly proven to us that getting to a doctor’s office isn’t always convenient,” Carmouche added.

    Market conditions

    While efforts toward more integration can yield enough leverage to negotiate higher reimbursement rates from payers, it’s important to know what is happening in a given market to assess how strong that leverage will be.

    An NIHCM Foundation study of 2008 to 2012 commercial claims data from the Health Care Cost Institute found that commercial insurers pay generalist physicians and specialists higher when they are integrated with each other, but the study also notes that “the majority of physicians now work in a multispecialty practice and the share is increasing.”3

    A flooding of a given market with CINs could ultimately lead to reimbursement rates dropping as pricing advantages fall amid a higher concentration of clinically integrated providers.4

    The next stage of telehealth

    One area of telehealth that may see additional growth as the pandemic winds down is eConsults, in which primary care physicians (PCPs) and specialists share patient information securely to minimize the need for a patient to follow up with a specialist.

    Since CINs emphasize interoperable data and population health, eConsults can improve care delivery and patient outcomes and experience by:

    • Enabling better data collection and analysis, for improved quality metric tracking and performance
    • Establishing chronic disease registries to improve chronic care management, which in turn improves population health and lowers costs
    • Addressing low-acuity patient needs more efficiently, which can boost specialist capacity and attention to high-acuity needs
    • Boosting rural care access.5

    Finding balance

    Creating a value equation for independent physicians, employed physicians, hospitals and other constituents in the care continuum of a CIN can be difficult, Carmouche said, but the patient focus built in the primary care setting will provide those downstream benefits.

    “Specialists actually get better referrals,” Carmouche said. “A good specialist, in our model, is not going to have to see 10 patients to do the one procedure that they’re trained to do.” Co-management of certain chronic conditions between primary care and subspecialists in the CIN leads to better patient flow to the right physicians “who can do the best work,” Carmouche added.

    That level of improved care is one way in which traditional healthcare organizations can stem the tide of retail health disruption from the likes of Walmart or CVS. “Those enterprises may take a different look at what hospital they want to use for [a given service], so the traditional referral mechanisms in and out of a community into a hospital become a little more perilous,” Carmouche said. “I think we see hospitals leaning in here to help, because they want to provide support to a provider organization that’s going to be successful and that will stay close to them for the services that need to be provided in the hospital.”

    Underneath all this work is physician leadership. “Physicians have to believe that being rewarded for taking better care of patients is a good and noble thing, and they lead a lot of the change,” Carmouche said. “Moving into this sort of supported model with a data infrastructure, payment for actually getting better outcomes and allowing physicians to spend a little more time with their patients has just been a real rewarding thing to see.”

    Notes:

    1. Department of Justice and Federal Trade Commission. “Statement 8: Enforcement Policy on Physician Network Joint Ventures.” 1996. Statement of Antitrust Enforcement Policy in Healthcare. Available from: bit.ly/3pP7pCo.
    2. Bendix J. “The challenges, and opportunities, of clinically integrated networks.” Medical Economics. Jan. 19, 2021. Available from: bit.ly/3aGp8rb.
    3. Baker LC, Bundorf MK, Kessler DP. “Does Multispecialty Practice Enhance Physician Market Power?” American Journal of Health Economics, 6(3):324-47, Summer 2020.
    4. Worth T. “Joining Integrated Networks to Improve Reimbursement.” Renal & Urology News. Oct. 28, 2020. Available from: bit.ly/3umw4RU.
    5. Cittadino M. “How Can eConsults Help Clinically Integrated Networks Deliver Better Care and Demonstrate Value?” HIT Consultant. June 24, 2020. Available from: bit.ly/3pGyqaI.
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