What is a Clinically Integrated Network?

Before we start talking about Rising Risk programs, we should understand what Clinically Integrated Networks are and the challenges they face in increasing market share. A Clinically Integrated Network (CIN) is defined as a collection of health providers, such as physicians, hospitals, and post-acute specialists that join together to improve care and reduce costs for their members. There are some important reasons why CIN’s are being formed. Here’s a few that we want to highlight:

  1. CINs aim to increase the market value of an organization by creating a low-cost, high-quality unified health care network destination
  2. They align independent physicians and reduce wastage in healthcare while providing employment for independent community providers
  3. CINs allow organizations the option to ease into participating in value-based care or risk contracts
  4. Additionally, CINs provide an avenue for independent physicians to prepare for value-based contracts (such as an ACO or MA plans)
  5. Lastly, and most importantly, CINs enable effective population health management and care coordination across the full continuum of care

While CINs do provide many benefits, they aren’t always intuitive to pursue. Running a CIN is a challenging mix of clinical, financial, interpersonal, legal, and regulatory elements among physicians and hospitals. The following is a high-level overview of the general advice we have for CINs after working with many organizations pursuing value-based care for the past decade:

  • The real issue is that many CINs do not invest in having the right tools to measure outcomes and performance. This is where many CINs fail over a period of time.
  • The key question for health systems should not be, “how do we build a CIN?”, but rather “how do we differentiate our CIN relative to other alignment options available to independent physicians in a specific market?” Recruiting and retaining a network of independent physicians can be the trickiest part of building a successful CIN.
  • Sustainable differentiation for one CIN over another should come through proprietary assets and technologies developed over time.
  • Providers in a CIN appreciate having access to better contracts and delivering services that add value to their beneficiaries like Rising Risk population health programs.

What is a Rising Risk Program?

We should now define the term Rising Risk. Members that move between low-cost and high-cost or low-risk and high-risk categories are called Rising Risk members. This is an important concept to know because most population health programs focus only on members that are already high-cost or high-risk.

We’ve found that on average, commercial populations have an annual 90% churn in their high-cost members. That means, if you focus your population health efforts on these members at the beginning of the year, by the end of the year, you would see that the cohort is made up of 90% of members that came out of left field and were not even on your list initially (Figure 1). That’s a significant lost opportunity and wasted resources. In addition, since most current population health programs focus on this cohort only after these members have already become high cost members, there is no way to avoid this initial cost.

Instead, population health programs should focus on both cost-reduction (by targeting members that are already high-risk or high-cost) and cost-avoidance (by targeting Rising Risk members). Check out our previous blog for more information about cost-avoidance.

Figure 1: Most population health programs are built around a retrospective look at members that were historically high-cost. That is an inherently flawed approach because we’ve found that commercial populations have a 90% churn rate in their high-cost population year over year. If this organization’s 2018 population health program was built according to who was high-cost in 2017, they would see that 90% of people who end 2018 as high-cost came out of left-field.

How do Rising Risk programs help CINs increase revenue and generate profit?

Rising Risk programs can create a “Multiplier Effect” for CINs in achieving marketing success. The tendency for an impression created in one area to influence opinion in another area is a very important variable for CINs. This is better explained with a diagram (see Figure 2).

  1. By focusing on Rising Risk members, providers in a CIN can improve health outcomes by identifying the risky cohorts early in the disease burden stage and developing the appropriate proactive intervention program.
  2. Targeted prevention and proactive programs to avoid adverse outcomes lead to improved member satisfaction, increased morale, and improved  employee productivity.
  3. This leads to more employers signing up for value-based contracts and thus increased market share.
  4. Primary care physicians notice that they are seeing increased members and primary care utilization service needs, making it attractive for additional PCPs to join this specific CIN.
  5. High-quality specialists make up for the drop in volume of patients with increased performance-based shared savings. The bad performers get left out of the CIN, while the best physicians get the added advantage of a narrow high-quality network.
  6. Continuous growth and shared savings attract the best PCPs and specialists, and this creates the “Multiplier Effect” in creating a low-cost, high-quality unified health care network destination.
Figure 2: The “Multiplier Effect” describes the phenomenon of the positive chain of events that reinforce each other in regards to the growth of a CIN.

The ability to analyze integrated data to target cost savings, care management, member engagement and performance improvement opportunities is a key element for a CIN’s success. Here’s what a CIN will need:

  • Front-end analytics for providers to assess their population’s state-of-health (SOH) leveraging predictive analytics to identify rising risk cohorts and design appropriate care management and member engagement programs
  • Risk stratification capabilities to identify and manage Rising Risk and high-risk patient populations for the CIN’s proactive & complex care management program.
  • Complement care management programs with member outreach programs with hyper-relevant messaging based on the psychographic segmentation of the membership.
  • Monthly performance measures are another critical component of a CIN program. Tracking these measures on how the programs are performing in cost reduction and cost avoidance through improved health outcomes allows the network to quickly identify and respond to poor outcomes and overutilization of costly services.

Overall, a CIN can deliver a differentiated and competitive product to its target markets with the proper tools and applications embedded into its ecosystem.

How Rising Risk programs can increase market share for Clinically Integrated Networks

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