High-performing clinically integrated networks (CINs) are an essential tool for health systems, hospitals, and physician groups to meet demands from employers and other purchasers for high-quality healthcare delivered in a cost-effective manner. CINs can help achieve these goals by creating a vehicle that aligns incentives, aggregates data, and drives process improvement across participants.
CINs can also help participants navigate economic pressures resulting from legislative and regulatory changes. For smaller hospitals and independent providers, CINs offer the ability to share back-office functions and spread overhead costs, creating economies of scale that would otherwise be unattainable.
Given the potential benefits, there has been a proliferation of CINs over the last 20 years. However, many are underperforming relative to their potential and their participants’ aspirations. In this article, we explore how healthcare providers can improve CIN performance by focusing on key areas including strong governance, achievable and measurable goals, and actionable data.
What Are the Indicators of a High-Performing CIN?
When evaluating CIN performance, organizations should consider both qualitative and quantitative factors. Two key qualitative indicators are physician engagement and the CIN’s ability to share actionable data.
- Physician Engagement: For a CIN to perform to its full potential, it must have a governance model that fairly represents physicians and actively engages them in decision making.
- Sharing Actionable Data: When physicians have access to actionable, relevant data, engagement increases significantly. It facilitates a culture of performance improvement, collaboration, and accountability. In addition, high-performing CINs view data as directional rather than absolute, using it to guide improvement. This pragmatic approach enables faster decision making and a focus on improving outcomes.
Creating the governance structures, data infrastructure, and cultural alignment necessary to succeed requires time. Those CINs that are patient when it comes to making the necessary investments in longitudinal data capabilities and nurturing physician engagement are better positioned to develop into high-performing networks that improve outcomes for patients, create value for purchasers, and improve financial outcomes for participants.
Quantitative performance indicators can vary depending on the CIN’s maturity and the degree of performance-based risk embedded in the various governmental programs and managed care contracts in which it participates.
- Early-Stage CINs: Early performance measures often focus on improvements within one care setting, such as reducing hospital-acquired infections or readmissions.
- Mature CINs: As a CIN achieves early goals related to improving outcomes in one care setting, the focus often evolves to managing population health and coordinating care across the continuum. The most sophisticated CINs may contract directly with employers, taking on performance and outcomes risk for defined patient populations.
What Role Does Governance Play in a CIN’s Success?
CIN performance is predicated on a governance structure that engages physicians, facilitates data sharing that allows providers to identify and act on improvement opportunities, and provides for efficient, fair decision making.
Governing boards of high-performing CINs typically include 8 to 12 physicians. This size allows for diverse perspectives while avoiding decision-making efficiency pitfalls that may come with a larger board. In the early stages, CINs should prioritize physician board members who are change champions and passionate about improving patient outcomes, not necessarily the highest billing providers. These respected physician leaders help build credibility, trust, and momentum with their peers. As the CIN matures, governance often shifts to leaders with greater administrative experience who can hardwire operations and expand on early successes.
What Key Performance Indicators (KPIs) Help Drive CIN Improvement?
Physicians are scientists by nature. They are trained to ground clinical decisions in data and evidence. The same principle often applies to their approach to the business of healthcare. By making credible, actionable data a foundational element, CINs empower physicians to drive continuous improvement. This not only enhances outcomes but also fosters the cultural transformation necessary to sustain long-term success.
KPIs serve to align physicians around measurable goals. In the early stages, CINs often focus on narrow, hospital-based metrics such as reducing length of stay or improving throughput. These initial goals are achievable and familiar, which helps build credibility. As CINs mature and take on increased performance-based risk, the measures begin to span the continuum of care, such as communitywide readmission rates and percentage of patients with A1C values within a normal range.
High-performing CINs tend to focus improvement efforts on leading measures—upstream actions physicians can realistically influence to drive downstream outcomes. Lagging measures, such as cost per adjusted admission or readmission rates, are also important to track, but they’re often too broad to credibly attribute to individual physicians’ behavior.
Root cause analysis of performance drivers allows CINs to identify leading measures and create metrics-based incentive structures that reward physicians for behaviors directly linked to shared goals. For example, in surgical settings, narrowing vendor selection in the operating room can reduce supply costs, which lowers overall admission costs. In primary care, improving appointment availability can reduce avoidable readmissions among those recently discharged by enabling timely follow-up. While lagging measures such as readmissions remain constant benchmarks, leading measures often evolve as providers exhaust initial improvement opportunities.
How Do Participation Agreements & Contracts Create CIN Alignment?
CIN participation agreements outline expectations for “citizenship,” define the leading KPIs upon which physician incentives will be based, and establish funds flow. Participation isn’t an all-or-nothing proposition, and many physicians maintain contracts outside the CIN based on their determination of the benefits of participating.
However, in high-performing CINs, the balance of contract participation typically shifts over time. Physicians may begin with only 5% of their contracts negotiated by the CIN, but within five years, that number may grow to 80%. This transition not only reflects the CIN’s ability to provide participants with effective governance and actionable data, but also its leverage to negotiate more favorable managed care contracts than what a physician group could negotiate on its own.
How Can Forvis Mazars Help?
At Forvis Mazars, we help CINs thrive by realizing their potential to improve health outcomes for the populations they serve and financial outcomes for participating providers. Our team has deep experience assisting CINs at all development stages with governance structures, data infrastructure, KPI development, incentive alignment, and other common challenges.
If you have questions or would like to conduct a strategic review of your CIN’s performance, please reach out to a professional on our team.