The implementation and use of clinically integrated networks (CIN) continues to be an essential strategy in the journey to value-based care. The healthcare delivery system continues to become more and more complex, with new technologies, ongoing changes in the competitive landscape with mergers, acquisitions, and partnerships, and challenging payer contracts that are heading to real risk-based contracts in multiple episodes and larger populations.
Adding to this growing complexity, the new Medicare Shared Savings Program (MSSP) Rule, “Pathways to Success,” requires ACO participants to move into full risk during the next one to three years. As we know, commercial payers will ultimately follow Medicare’s lead in moving risk to providers.
Clinically Integrated Network Support
In this environment, clinical integration requires support for growth into risk-based contracts through optimization of operations and analytics, improving partnerships, and expanding networks while continuing to meet Federal Trade Commission (FTC) and/or Centers for Medicare and Medicaid Services (CMS) accountable care organization (ACO) requirements.
Acceleration through the continuum of payment models requires an evaluation of the data platforms and information available to a CIN. Risk-based contracts will require data that can be used to develop actuarial and financial models that allow an organization to predict the costs in a given population. This information is essential for analyzing whether a risk-based contract can be managed with positive results for providers and the CIN.
Claims and clinical information must also support the identification of high-risk, low-compliance populations to develop specific programs to help improve the outcomes in these populations. Finally, the available data need to support the management of total cost of care, meaning that the CIN needs clinical and financial data across the network to manage utilization, quality, and cost.
The Upside of Clinically Integrated Networks
Many CINs have performed very well and have shared gains with providers under upside incentive contracts. As CIN leaders evaluate upside and downside payer contracts, new relationships and models are required. For many organizations, secondary market network development may be important to manage the total cost of care. These relationships may include the development of a multi-market CIN, or “Super CIN,” or new affiliations and additional merger or acquisition activity. The entire network will need to operate efficiently and have aligned incentives.
Physician readiness is a crucial component of growing value-based contracts. Physician leaders need to be prepared with information and management strategies to drive performance within a contract. Historically, many CINs concentrated on primary-care incentive strategies in a full risk environment; now, specialty care providers, including physicians and ambulatory and post-acute care providers, will need to be included in an incentive structure to gain participation in the development and execution of clinical programs designed to improve compliance and quality. New training in risk-management strategies and new incentive strategies will be necessary to reach these goals.
The contracting process for risk-based contracts requires additional analysis than commonly completed in shared savings agreements. A contract must represent a large enough population to spread the risk based on actuarial analysis. In the absence of this analysis, an organization is at greater danger to have negative performance against contractual financial benchmarks.
Risk-based contracts also need to hold all stakeholders accountable, meaning the CIN and its providers, payers, and, in some circumstances, the employer. As discussed earlier, incentive methodologies that reflect the actual requirements of the contract and communicate these requirements regularly and effectively will enhance the opportunity to perform well. Finally, the contracting organization must have appropriate capital reserves to protect itself in case of negative performance.
These strategies, combined with continued operational efficiency and ensuring ongoing compliance with FTC and CMS regulations, will improve your health system’s ability to be successful in a risk-based environment.
Lynda Mischel is managing principal for Lumina Health Partners.
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- Why ACO Compliance is a Critical Element of Achieving Success in 2019