Evaluating Clinically Integrated Networks – What Should My Practice Consider Before Joining?

by Wythe Michael

With the implementation of the Affordable Care Act, numerous Accountable Care Organizations (ACOs) have been established – especially ACOs focused on Medicare patients. More recently, we have seen an expansion of clinically integrated networks (CINs) that include a focus on contracting with nongovernmental payers and broader participation from practitioners.

CINs are groups of providers that have organized to manage care for specific patient populations. Participants in CINs can include hospital systems, groups of practitioners employed by a hospital, ACOs and independent local practitioners. CINs adopt protocols and policies to improve the quality, safety and cost effectiveness of the care delivered by practitioners. Although a hospital system will often help set up the organization and will assist in the management and operation of the CIN, CINs should be led by physicians.

Participants in a CIN enter into a participation agreement that governs the participant’s relationship with the CIN. The agreement requires individual practitioners to participate in the operation of the CIN – often on governing committees. It also requires participants to comply with the protocols and policies of the CIN. Importantly, the agreement typically gives the CIN the right to negotiate managed care agreements with third party payers, including the right to negotiate – on behalf of participants – fee-for-service arrangements and shared savings payments.

For practitioners, the main benefit of participating in a CIN is that it allows the practitioners to jointly negotiate and enter into contracts with payers. With the expected cost savings and enhanced quality achieved by the CIN, this can result in higher reimbursement rates. Participating in a CIN also ensures that participants aren’t left out of important local provider networks.

One disadvantage of a CIN is a perceived loss of independence. A second disadvantage is the potential cost of upgrading software and other EMR systems to work with the CIN’s system. A third disadvantage is the additional time practitioners must spend on CIN governance, operations and protocols. In deciding whether to join a CIN, practitioners should consider, among other things, the following:

  • Does the CIN require an upfront payment or capital contribution?
  • What are the EMR system requirements of the CIN?
  • What are the other participation requirements?
  • Is the CIN physician led? Are the physician leaders independent or part of a group employed by the hospital? How is the board elected?
  • Has the CIN adopted protocols? If not, what is the process and timing for developing protocols?
  • What type of authority does the CIN have to negotiate payer contracts on behalf of participants? Are any such contracts already in place?
  • Does the CIN permit practitioners to participate in another CIN?
  • How will cost-savings and quality bonus payments be shared with participants?
  • Is the CIN a narrow-network or more broadly based?
  • Will the CIN engage in promotional or marketing efforts?
  • How can the CIN terminate participants? How can participants resign?

With third-party payers continuing to seek additional cost savings, we expect participation in CINs to continue to grow. Accordingly, practitioners should be prepared to proactively evaluate potential CIN options.

This article published in Hampton Roads Physician, Summer 2016 issue.

This blog is made available by Goodman Allen Donnelly for general information, and does not constitute legal advice. By reading this blog, you understand that there is no attorney-client relationship between you and the firm. This blog should not be used as a substitute for competent legal advice from a licensed professional attorney in your state.