Health Information Compliance Alert

Published on Mon May 16, 2016 PDF

But don’t let your data become a ‘goldmine’ for medical malpractice attorneys.

If you’re a small or mid-size provider, you need all the help you can get to stay afloat in today’s healthcare landscape. One solution that providers are increasingly testing out is participating in a clinically integrated network (CIN). But do CINs actually help you to utilize data to improve reimbursement and quality of care?

Understand the Benefits of CINs

What is it? A CIN is much like an Accountable Care Organization (ACO). A CIN is an alignment model, coordinating care across affiliated providers and developing contracts with payors to improve care quality while controlling costs, according to the GE Healthcare Camden Group. CINs also include value-based contracting initiatives with commercial payors and Medicare.

“We are entering an era in which healthcare reimbursement from government and private payors will be based on value instead of volume,” says Seattle-based attorney Casey Moriarty with Ogden Murphy Wallace PLLC. “In order to survive the shift from the fee-for-service model to the value-based model, providers must learn to streamline operations and provide quality care at lower costs.”

One way providers can improve their chances of thriving in a value-based reimbursement world is to form a CIN in which providers cooperate to control costs and ensure quality, Moriarty notes. “By forming such a network in compliance with antitrust laws, independent providers are able to combine resources and even jointly contract with payors.”

Estimates indicate that more than 500 CINs are currently in operation across the United States, according to the Camden Group. Leading CINs tend to share certain attributes and capabilities, including:

• Physician-led organization with a focus on quality of care within a patient-centric model;
• Care management capabilities to help improve quality and outcomes while reducing costs;
• Clinical programs that optimize services for specific diseases and patient groups;
• Advanced technology leveraged to improve electronic interoperability, standardize optimal care, and improve services at the point of care; and
• Population health capabilities that allow the CIN to aggregate data and manage the high-level factors that influence health outcomes.

Get the Data Flowing

One key component of a successful CIN “is the free-flow exchange of data between providers,” Moriarty states. “The data exchange will allow the network to establish procedures to monitor the utilization of healthcare services and also create best practices for the providers.”

Exchanging data will also allow the CIN to create performance metrics and distribute incentive funds to high-performing providers, Moriarty adds. And the CIN can “use the data to provide a performance report to physicians and let them know how their performance compares to other physicians in the network.”

All this data exchanging won’t be easy, however. And IT is the largest single investment an organization will need to make in developing a CIN, noted Dudley Morris, senior advisor with BDC Advisors, in a recent Q&A.

Don’t Overlook the Risks

But when you’re exchanging this much data, there are certainly risks for HIPAA problems. Yet, experts point to another less-obvious issue with data sharing in a CIN.

You need to be aware that “any data shared between a network and a provider could be subject to discovery in a lawsuit,” Moriarty cautions. And performance data in a CIN “could be a goldmine for a malpractice attorney.”

What to do: To protect your data from such discovery, you should comply with any state peer-review privilege laws, Moriarty suggests. “Another option is to form a ‘patient safety organization’ under the federal Patient Safety Quality and Improvement Act (PSQIA). The PSQIA has a broad privilege for certain information that is submitted to a patient safety organization.”

Bottom line: Although CINs and similar care structures are seemingly the inevitable future of healthcare, the move from fee-for-service to value-based care may be too large a leap for many providers in a single bound, particularly if you’re aiming to join or create an ACO, according to BDC Advisors. Developing a CIN first to provide the foundation for ACO-style care delivery will help you to establish the data systems to measure performance-based outcomes.