While CINs enable health systems and providers to deliver value-based care, they come with many clinical and operational challenges, including in those related to technology, governance, organizational alignment and care coordination. And there are very real compliance threats. The U.S. Federal Trade Commission, Department of Justice and state regulators closely scrutinize the structures of these networks to safeguard against antitrust violations.
A growing number of CINs are leveraging Clinical Integration Accreditation to ensure their framework positions their organization to meet the many clinical, organizational and financial challenges they will face.
Two such organizations are Phoenix Children’s Care Network (PCCN) and Seattle Children’s Care Network (SCCN). (Hear directly from these two CINs in this webinar on October 25: The Path to Clinical Integration).
When Phoenix Children’s Care Network (PCCN) began its journey toward clinical integration five years ago, it needed an organizational framework that would give it legitimacy with payers. Because PCCN would be negotiating contracts with insurers and paying quality-based incentive bonuses to its 1,000 providers, there was inherent risk of inducing referrals and perceived anti-competitive practices if the arrangements weren’t structured carefully.
“We are the pediatric player in our region, so the fear was that if we were aggressive in negotiating contracts, an insurer could report us for colluding and trying to drive up costs. We needed to structure [PCCN] so that no one could poke holes in our internal processes,” says Casey Osborne, vice president of PCCN, which is now the largest pediatric-dedicated, clinically integrated organization in Arizona and one of the few networks of its kind in the U.S.
“URAC has done a thorough review of federal and state regulations,” Osborne says. “Their accreditation process really helps you ensure that your CIN is set up in proper fashion and has the proper structure in place.”
For example, URAC’s standards require CINs to create an infrastructure that aligns with requirements established by the Centers for Medicare and Medicaid Services (CMS) as well as other federal and state agencies.
“Because of this, payers don’t have to worry about the risk they’re delegating by allowing our clinically integrated network to provide services to their patient population,” Osborne says.
Other URAC standards guide CINs through establishing the infrastructure and policies necessary for transparently monitoring its accounting and financial practices.
“Achieving URAC accreditation really gave us credibility,” Osborne says. “We can demonstrate that we’re keeping proper documentation and audit trails and that we’d perform well if any regulator decided to come in and audit or review the services we’re providing on the payer’s behalf.”
Accreditation recently helped PCCN land a contract with a commercial health plan to serve as its exclusive network for pediatric care. “Our URAC accreditation showed that we have all of the processes and governance in place,” Osborne says. “The fact that we’re accredited by URAC has allowed us and the payer to focus more on operationalizing the product and less on reviewing our capabilities and core competencies.”
When SCCN first went operational in 2015, it set out to be the best manager of pediatric lives in the Pacific Northwest and to ultimately move toward single-signature contracting. But first the network had to ensure seamless information exchange between its members, which include Seattle Children’s Hospital, a 650-specialist medical group and 21 primary care practices.
“When you’re in a clinically integrated network, no longer are you looking at whether a physician did a good job when a patient came to their primary care practice,” says Michael Murphy, SCCN’s executive director. “You’re looking longitudinally at the patient across all sites of the organized system of care. You’re looking at metrics and measures that span across the continuum of care, at how frequently patients come, the dynamics that drive utilization and how to collectively implement interventions, care coordination and care management.”
SCCN, is currently going through the URAC accreditation process. “Other than going to the FTC and getting their sign off, which is a lengthy, costly direction to go, URAC accreditation is the best way to be recognized as a vibrant clinically integrated network,” says Murphy.