CMS recently calculated that the United States spent $3.8 trillion — or 18 percent of the gross domestic product — on healthcare in 2019. The current healthcare landscape indicates this spending rate will not slow anytime soon due to the COVID-19 pandemic, an ongoing healthcare crisis. Value-based care models like Accountable Care Organizations (ACOs) and Clinically Integrated Networks (CINs) have formed to address the alarming growth in healthcare spending and simultaneously improve the quality and coordination of care in the U.S. Let’s take a look at these models and their ability to secure value-based contracts for better disease and population health management. 

ACOs Generate Value and Cost Savings 

According to the National Association of ACOs (NAACOS), 512 Medicare Accountable Care Organizations (ACOs) account for 12 million Medicare beneficiaries as of January 2021. As reported by NAACOS, these Medicare ACOs have saved Medicare $8.5 billion in gross savings from 2012 to 2019. The ACO model in particular is advantageous for providers and health systems who are aligned to manage chronic conditions or complex diseases across their patient populations. If successful in cost control, the ACOs share in the savings of this low-cost, high quality care model. Transformative ACOs share five common objectives to provide value and clinical care efficiencies. 

1. Advanced coordination amongst patient’s care team 
2. Exceptional patient experiences 
3. Patient-centered communication 
4. Combined, longitudinal electronic medical record 
5. Quality metrics reporting and data analytics 

Medicare Shared Savings Program (MSSP) providers will be impacted by CMS’ 2021 regulation that include several positive adjustments. Transformative care models like ACOs and CINs must encompass data, analytical, financial and patient care pillars to prove value in their high quality, patient-centered care delivery.  

Clinically Integrated Networks (CIN) Defined 

The formation of a Clinically Integrated Network (CIN) enables providers to remain independent while aligning with other providers under a network umbrella for patient care coordination. The American Medical Association (AMA) describes clinical integration as “the means to facilitate the coordination of patient care across conditions, providers, settings, and time in order to achieve care that is safe, timely, effective, efficient, equitable, and patient-focused.”  

There are many benefits to providers participating in CINs. 

1. Physicians are able to maintain their practice independence while joining together to negotiate better managed care rates 
2. Using metrics and quality data, CINs can prove an increase in care quality along with cost savings and spending efficiencies 
3. A CIN can support multiple managed care contracts 
4. CINs are recognized by the FTC with standards and guidance to define clinical integration 

 

Practice transformation will support collaborative care that is patient and data-centered to reduce spending waste while excelling in care quality and value. A holistic approach for achieving clinical integration includes:  

• Defining clinical practice guidelines and efficiencies for high quality, low cost care that can be monitored and controlled 
• Aligning with providers who are committed to managing patient populations efficiently 
• Measurement and evaluation of each participating provider’s compliance with the guidelines 
• Investment in people and technology to fuel clinical integration and implement practice guidelines for care and quality efficiencies   

A CIN is a viable option for independent physicians to participate in a value-based care model. Information sharing and measuring value-based performance will ensure accountability across participants. 

Barriers to Clinical Integration 

Manual efforts involved in reporting, accessing and referring patient data can derail productivity and positive clinical outcomes. CINs that have the technological tools, where the data follows the patient and prompts for follow-up care will be most successful and poised for advanced value-based care models. The advantage of data analytics when negotiating value-based contracts is astronomical. Beyond data analytics, physicians must address potential barriers to forming a CIN. 

1. Differing Electronic Health Record Systems (EHRs) that lack integration
2. Manual efforts to extract, combine or pool data become costly and less likely to occur 
3. Lack of workflow automation to manage in-network patient referrals 
4. Data analysis capabilities to assess quality, cost and care metrics 
5. Physician champions for IT infrastructure and usage 

Health care providers without comprehensive data analytics solutions to stratify risk and identify care gaps are at a disadvantage when it comes to negotiating the best contractual terms with payers in the value-based care marketplace. Tools for clinical decision support and care management determine the effectiveness of payer-provider collaboration. 

CIN Success 

Throughout Pennsylvania, physician-owned practices are collaborating and succeeding as a clinically integrated network. Specifically, the Care Centered Collaborative assists independent physicians and physician groups in establishing or further enabling select Clinically Integrated Networks (CINs). The multi-year joint venture creates the opportunity for these CINs to secure value based care contracts with payers. I was thrilled to expand on this discussion alongside Dr. Jaan Sidorov, CEO and President of The Care Centered Collaborative at the Pennsylvania Medical Society, with the Medical Group Management Association.  

The Collaborative’s population health management platform received data from 160 providers initially that included claims and clinical information across 23 different EHRs over two years. Population factors to be analyzed: 

• Patients at highest risk for emergency department visit, readmission or complications 
• Duplicate test and other redundant or unnecessary care  
• Targeted population areas with high incidence of specific pediatric disease for targeted programs and interventions 

Recently, the Pennsylvania Clinical Network entered into a value-based agreement for Aetna’s Medicare Advantage members in Pennsylvania.  

Conclusion 

CINs will be able to increase their geographic footprint through contract, network and services expansions. The ability to scale their operations will determine how efficiently and effectively they can manage patient population growth. Replicating the same care value models that achieve high quality, exceptional patient experiences and reduced costs is attainable with engaged physician and clinical leadership partnered with the technology capabilities to manage patient influxes. 

ACOs and CINs address the problem of rising healthcare costs and answer the call to improve care quality. These care models successfully move the needle on disease management and accelerate patient-centered data capabilities. As the healthcare landscape continues to evolve, the fundamentals of ACOs and CINs remain unchanged: engaged physicians, cross-community patient data and population health management tools. Opportunities arise for more healthcare providers to share in the savings and achieve success through alternative payment models, and that is invaluable to transforming healthcare delivery. 

Do you have lessons learned or a story to share with your value-based arrangement? Connect with a HealthEC member and let’s discuss!