• Case Studies in Clinical Integration

    By Lola Butcher Nov 17, 2016

    Many health systems and physicians are using the clinically integrated network model to facilitate their transition from volume-based payments to value-oriented care delivery.

    A study published nearly a decade ago using data from 2000 remains the siren song for clinical integration: In one year, Medicare patients saw a median of two primary care physicians and five specialists working in four different practices.1

    That analysis documented the highly fragmented nature of America's healthcare system and fueled the push to find a better way. Operating in their traditional silos, healthcare providers are destined to duplicate tests and treatments, make decisions without information from other providers, and run up costs.

    The antidote is clinical integration that allows providers to work together seamlessly, providing better care for patients and reducing the waste that drives up the nation's healthcare tab. Indeed, any successful move to value-based payments and population health management will require clinical integration among an array of providers.

    In recent years, the term clinical integration has become an industry catch phrase used to describe everything from vague collaboration among longtime rivals to mergers that bring hospitals and physicians under single ownership. The term clinically integrated network (CIN) refers to a specific legal arrangement that allows competing providers to jointly contract with payers without running afoul of the Department of Justice and the Federal Trade Commission.

    To stay on the right side of antitrust laws, a CIN can be a physician-hospital organization, an independent practice association, or the subsidiary of a health system, but it must have physician leadership baked into the governance model. All CIN members must formally commit to complying with clinical guidelines and working on performance improvement activities. Data sharing and performance monitoring are required. And the CIN must demonstrate that it is improving value, not just using its size to wrangle better rates from payers.

    Christiana Care Health System started exploring the CIN model as it considered the implications of the Affordable Care Act.

    "We want to make the transition from being a very successful acute care hospital to a healthcare system that is contributing to the health of the community," says Alan Greenglass, MD, CEO of Christiana Care Quality Partners (CCQP), a statewide CIN in Delaware. "And we know that just doing more things for the sickest people is not going to be the future, so we needed to find a way of providing as much value in our care as possible."

    The Advisory Board counted about 500 CINs nationwide at the end of 2012, and more have launched since.

    "We are not going to be successful unless we have a strong partnership with the physicians in the community," Greenglass says. "What is the best way of doing that? We said it is clinical integration around the Triple Aim."

    Regional Reach

    The Vanderbilt Health Affiliated Network (VHAN)—started by Vanderbilt University Medical Center (VUMC) and four other hospital systems in 2012—includes 12 health systems that encompass more than 50 hospitals and 3,500 clinicians. While Tennessee is VHAN's primary market, the network's clinical practice improvement and consulting activities reach into Georgia, Alabama, Mississippi, Arkansas, and Kentucky, and may go even further afield.

    "We have lofty aims," says David Posch, VUMC's executive vice president of population health. "Our intent is really to transform how healthcare delivery across the mid-South occurs so that we improve the health of millions of people in the region."

    The Centers for Medicare & Medicaid Services (CMS) thinks VUMC and VHAN are up to the task. CMS recently gave VUMC a contract for up to $28 million over four years to help more than 4,000 VHAN participants and other clinicians transform their practices by spreading the use of informatics tools and other supports. The contract is part of CMS's Transforming Clinical Practice Initiative, which seeks to help 150,000 clinician practices develop comprehensive quality improvement strategies.

    Focusing on care for patients with chronic diseases, the contract comes with big goals: reduce unnecessary testing and treatments by 5 percent and hospital readmissions by 20 percent by the fourth year of the program.

    Such objectives directly support what Posch and his colleagues are working on. Clinicians and hospitals that belong to the network pay annual dues to support VHAN's infrastructure and agree to participate in performance improvement activities, data sharing, and care coordination. "We have a fairly elaborate medical director structure that meets with our practices and engages them in these efforts," Posch says.

    One focus is the use of cost-effective pharmaceuticals, which is monitored on dashboards tailored to regional dynamics. "Pharmacy is approaching 30 percent of the cost of insurance premiums, so that is a very important element of where we work," he says.

    VHAN is rolling out a health information exchange that will allow electronic health record (EHR) data to be shared among providers--and promote evidence-based care.

    "Our aim is not just to be able to exchange data but also to embed clinical decision support into those electronic medical record systems so we provide real-time support about the best evidence-based practice," he says.

    The network currently provides care for more than 110,000 patients, the majority of whom are from self-insured employers, including the 12 health systems that participate in the network. By 2020, VHAN leaders expect to be responsible for at least 1 million lives.

    The sales pitch is compelling: The CIN's pediatric program cost 17 percent less than the market trend in 2014, the latest year for which information is available. In adult services, VHAN and its participants saved employer and commercial health plans about 5 percent--or $10 million--in 2014.

    Originally envisioned as a much smaller entity that would serve central Tennessee only, VHAN has grown quickly as other health systems and physician practices have sought to be included. The move to value-based payment methods transfers financial risk to physicians and hospitals, which requires managing patient care across providers and over time.

    "Everybody realizes we need to organize ourselves in such a way that we can understand the care of our patients and do a better job of it as we go forward," Posch says. "The idea of a provider-driven organization that is dedicated to those principles has resulted in a fairly rapid growth."

    Physicians Come Aboard

    Christiana Care, the biggest health system in Delaware, likewise found physicians eager to sign up when it launched its CIN in 2014.

    The health system initially invited all physicians on its medical staff to participate at no expense--and CCQP quickly grew to include 1,500 primary care and specialty physicians, most of whom are in independent practices.

    That worked well for CCQP's first patient population--Christiana Care's employees and their family members. "That almost guaranteed that every physician in the geography would be in the network and that there would be no out-of-network problem for our employees," Greenglass says.

    On the other hand, many physicians signed up to be part of CCQP without considering or committing to the practice changes--such as robust data sharing, care coordination, and standardized care protocols--that are needed for the CIN to succeed.

    That's why CCQP selected a much smaller group--about 200 primary care physicians--with which to pursue a Medicare Shared Savings Program ACO contract. "It is really hard to change the behavior of 1,500 physicians," he says.

    That said, the large network has its benefits. CCQP's governance and committee structure gives value-oriented physicians a chance to emerge as leaders with responsibility for understanding how healthcare delivery must change and for making decisions on how CCQP physician practices must respond to industry trends.

    Christiana Care Quality Partners Governance Structure

    The governance structure used by the Christiana Care Quality Partners clinically integrated network.

    "We are seeing the next level of healthcare leadership coming from the private physician community--people who did not know how to participate in the past," Greenglass says. "That is a strength because, for our community to change, those private physicians need to be engaged."

    Alan Greenglass, CEO, Christiana Care Quality Partners. (Photo: Christiana Care Quality System)

    CCQP's third-party administrator analyzes claims to create quarterly performance reports for CIN physicians. And the CIN has developed a fledging pay-for-value model that rewards primary care physicians and some specialists for their performance on customer service, preventive care, and chronic care measures.

    Scott T. Roberts, MD, a partner at Christiana Spine Center, serves on a CCQP committee and thinks the CIN will realize its potential only when electronic data sharing supports true integration. CIN participants use different EHRs and, with no platform that allows data to be exchanged, faxing remains the most common mode of communication. "That is the single largest limitation to our ability to actually be integrated, to improve patient care, to decrease redundancy, to share outcomes data, and to develop appropriate standard- of-care pathways," he says.

    The Rise of the Super CIN

    In Michigan, Together Health Network (THN) has emerged as a "super CIN" composed of nine local CINs that cover the state. THN was formed in 2014 by two large health systems, Ascension and Trinity Health. The University of Michigan Health System joined as an equity partner and quaternary care provider this year.

    The network includes more than 5,000 physicians and 29 hospitals, and its leaders estimate that 75 percent of Michigan residents live within 20 minutes of a THN provider. THN's vision is to be the preferred partner of anyone--patients, physicians, or payers--looking for care models that deliver on the so-called Quadruple Aim: better care for individual patients, better population health, lower healthcare costs, and better experiences for healthcare providers. "We want to be the recognized entity that is able to deliver on that consistently across the state," says Scott Eathorne, MD, president and CEO of THN.

    While some CINs use a top-down approach to set and achieve their goals, THN is using an incremental strategy that builds on the progress of the nine local CINs. Eathorne relies on the individual CINs for leadership, governance, data sharing, and support for the physicians and hospitals in their respective groups. Although each CIN has its own priorities and processes, status as a CIN demonstrates the shared goal of improving the value of care delivery in the local community, he says.

    Over time, THN will develop its own capabilities on top of what each individual CIN maintains. "We are striving for more clinical integration, and that is why we are spending the time to understand where folks are currently and where we have the opportunity to integrate our clinical informatics systems, our network analytic systems, and our performance improvement processes," he says.

    Eventually, THN will implement a dashboard that supports performance improvement throughout the super CIN.

    "We are working to establish a common care model by which we work with each of the groups to decrease variation in the care that is provided," he says. "That will be largely managed at the local level."

    So far, THN has only one contract--a Medicare Advantage HMO contract sold in an 11-county region that includes the Detroit area plus Kalamazoo County--but it is positioning itself to add more. As value-based contracts become more common, the individual CINs will be increasingly attractive to payers and employers if they are part of a statewide network. "We are not looking to replace existing contracts that our local CINs have, but as we look for value-based opportunities, we anticipate that there will be a shift to the statewide network over time," Eathorne says.

    Payment reform ultimately will determine which care transformation models deliver on their promises, Eathorne says.

    "We know that there is not going to be any one single model that is going to be the solution to all of our healthcare woes," he says. "We think that in our community and our marketplace, we are fairly well poised to demonstrate our value proposition over time."

    Read more: Clinical Integration Supports Population Health Management

    Lola Butcher writes about healthcare business and policy topics for several HFMA publications (lola@lolabutcher.com).

    Interviewed for this article:  Alan Greenglass, MD, CEO, Christiana Care Quality Partners, Newark, Del.; David Posch, MD, executive vice president-population health, Vanderbilt University Medical Center, Nashville; Scott T. Roberts, MD, partner, Christiana Spine Center, Newark, Del.; Scott Eathorne, MD, president and CEO, Together Health Network, Southfield, Mich.


    1. Pham, H.H., et al., "Care Patterns in Medicare and Their Implications for Pay for Performance," New England Journal of Medicine, March 15, 2007.