Clinically integrated networks (CINs) consist of like-minded healthcare professionals that engage physicians, connect providers and hospitals, share data, improve patient care, and decrease overutilization. While they are generally made up of independent physicians, they can also include health systems.
Beyond the enhanced care provided to patients through access to more data and resources, another significant benefit is enhanced negotiating power with payer organizations, leading to more favorable reimbursement rates and contract terms.
A CIN that aims to succeed under value-based principles requires strategic alignment and an enhanced toolset to support operational changes to members’ day-to-day workflows and technology-based resources. In Lightbeam’s experience, to promote enhanced quality of care and cost efficiency, clinically integrated networks require:
- Complete digital health records
- Bi-directional data integration to support physician workflows
- Risk stratification methodologies
- Referral management capabilities
- Robust care management proficiency
Complete Health Records
A CIN needs to create a holistic view of their patients using data from clinical and claims systems. The comprehensive data creates a foundation for effective population health management. Since a single electronic health record (EHR) does not offer all of the necessary data within a single source, CINs need to put the infrastructure in place to not only capture data from disparate sources but normalize it as well. The infrastructure needs include an enterprise data warehouse and, in many cases, a health information exchange (HIE). With these solutions in place, CINs can collect, organize, analyze, and stratify data to share critical insights with providers within the network. Such insights might include gaps in care, coding opportunities, or information or alerts regarding transitions of care.
Bi-Directional Data Integration to Support a Physician Affinity Strategy
A physician affinity strategy aligns physicians and other members of the CIN with maximizing the efficiency and effectiveness of their practices. A successful comprehensive physician affinity strategy will have several components, including well-thought-out technological enhancements. For example, one incredibly valuable technological advancement involves combining all available data on a single platform and creating a common way to view and analyze it, as dictated by the network’s underlying strategies. One of the most powerful ways to support this is through bi-directional data integration, through which the vendor of the CIN’s population-level platform not only pulls data from the various EHR systems but also pushes data back, thus making insights and opportunities available at the point of care.
Risk Stratification Methods
It is important to utilize predictive methods to stratify risk accurately and discern a patient’s likely path through the healthcare continuum. Specifically, organizations would like to understand the likelihood of expensive and potentially preventable episodes of care, such as emergency room visits and inpatient admissions. Some of these measurements include hierarchical condition category (HCC) coding, the Johns Hopkins ACG® System, the Elder Risk Assessment (ERA), the Charlson Comorbidity Index, the NYU Algorithm, and Milliman Advanced Risk Adjusters (MARA). This potentially complex process is simplified when performed within a unified platform, whereby all risk models can be viewed and analyzed at once.
Referral Management Capabilities
Using an integrated referral solution to match and manage patient referrals helps support the goals of well-organized CINs. These solutions support closing the patient care loop between primary care and specialists; they should enable physicians to create preferred provider networks and match specialists based on quality outcomes, costs, location, and patient preferences. CINs need to keep patients in-network as much as possible and manage that network without adding significantly to organizational overhead. Network leakage and the resulting costs can mount quickly if high-risk patients regularly receive services from out-of-network providers. For all of these reasons, referral management solutions can often generate a positive ROI in a short period.
Unified Care Management Practices
Operations should remain unified throughout, but especially when it comes to care management. CINs are made up of many different providers with different styles of treatment; organized CINs should rely on one means to track compliance to care plans, approach intervention, and close care gaps in populations. The need for unified care management intensifies if they are thinking of contracting for risk. Without access to a patient’s health information to deploy immediate care, providers in a CIN may find themselves at a disadvantage, facing higher utilization costs and potentially poorer outcomes.
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Kent Locklear, MD, MBA is Lightbeam’s Chief Medical Officer.