August 28, 2024 • 27 mins
In this episode, Aaron sits down with our very own Jason Crosby to talk about CINs, how they work, how to start or join one, the keys to a successful CIN, the potential for legal pitfalls, and how CINs may fit the greater goal of providing value-based care.
Credits
Production Assistance & Editing: Nyla Wiebe
Scripting by: Aaron C Higgins
Show Notes & Transcription: Aaron C Higgins
Social Media Management: Jeremy Miller
News Co-Hosts: Aaron C Higgins & Jason Crosby
Interview hosts: Aaron C Higgins
Executive Producers: Mike Scribner & John Crew
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Aaron (00:05):
Welcome to Beyond the Stethoscope Vital Conversations
with SHP.
As we take our summer break toprepare for the exciting Season
5, we're revisiting some of ourmost insightful episodes to keep
the conversation going.
In this episode, originallyaired all the way back in Season
1, we explore the fascinatingjourney of building a healthcare
network from the ground up.
Jason Crosby, our residenthealthcare expert with over 25
(00:30):
years of experience, joins us todive deep into the world of
clinically integrated networks,or CINs.
From the challenges ofvalue-based care to the legal
intricacies of forming a CIN,jason shares his extensive
knowledge and experience.
So, whether you're a healthcareprofessional or simply curious
about the inner workings of thisvital industry, this episode
offered a unique glimpse intothe evolution of healthcare
(00:52):
networks.
Don't miss this opportunity torevisit an essential
conversation that remainsrelevant today and, as always,
if you find this episode helpful, please rate and share our
podcast in your favorite podcastapp.
It really helps us reach morelisteners.
Let's join Jason Crosby andmyself as he takes us behind the
scenes of CINs.
Jason (01:17):
Hey, good morning Aaron, Good morning everybody.
Good to be here.
Aaron (01:20):
Yeah, alrighty.
Well, we are here today with,actually, what should be a
fairly familiar voice is JasonCrosby.
You may have heard him doingsome interviews as well, and so
we're going to talk, though, notabout how to do a podcast, but
some of the other things thatJason is well versed in, and so,
(01:44):
I guess, help us understandJason.
You know what, what is yourbackground, you know what, what
makes you a vital conversation.
Jason (01:53):
So my first taste of healthcare came about 25 years
ago actually, during kind of anundergraduate internship at a
local health system with acouple of different units in the
hospital, and from there I wasjust hooked and so fast forward
a few years, went through gradschool all that it's my first
air quotes.
(02:14):
Real job was an entry-leveldescent support analyst at a
different health system, Wasthere for several years in
descent support and IT, did theproject management thing, did
the Six Sigma and ended upmanager of decision support,
which was my first managementgig and probably still to this
(02:36):
day one of my favorite jobs.
I really enjoyed that Leftthere, became finance director
for a large ER physician groupand then came to SHP about 13
years ago and so, honestly, thewhich, looking back the health
system and the practice settings, really, I would say, helped me
(02:58):
greatly coming into aconsulting world you know,
wearing multiple hats and tryingto be all things in all
settings and so that's, that'skind of been the journey.
Aaron (03:10):
Wow, yeah, you kind of run the gamut of health care
types too.
You know the hospital world tothe practice world and now the
consulting world.
So I know one of thespecialties that you deal with
within SHP are are CINs.
Tell me a little bit aboutthose for those in the audience
(03:32):
that may not be familiar withwhat a CIN is, and you know how.
How are you engaged with that?
Jason (03:39):
Yes, let's.
Let's get ready for athree-letter alphabet soup here.
Um, cin, a clinicallyintegrated network.
So go back about 25 years, 30years or so, the FTC came in and
the Federal Trade Commissionestablished their formal
definition.
And not to bore everybody withwhat that is, but it highlighted
(04:01):
some key words that areapplicable to everybody,
listening today, right, andexist in another form of CI
definitions Independence,cooperation, collaboration,
modifying practice patterns,controlling cost, improving
quality those same things wehear about today that are still
(04:22):
a consistent sort of basis or atheme that providers work from
today.
But in essence, a CIN is simplyas a clinically ingrained
network, even though it's gotmany definitions, it's its own
legal entity.
It's comprised of multipleorganizations, including
providers, physicians, healthsystem, age layer groups, et
(04:42):
cetera.
That basically it's intended toachieve what we now know and
call the AAA and principle ofhealthcare, right?
So these entities, they take onvarious forms, various modes of
evolution, the most typicalbeing your PHO, just adding
another three-letter acronym outthere Physician Hospital
(05:04):
Organization, type of entitywhere you have a hospital
alongside their employedphysicians, sometimes the
community independent providers.
The other common form we see isa collection of independent docs
or an IPA.
You know each of which we'veworked with in the past and we
do today.
So we're an IPA, you know eachof which we've worked with in
(05:26):
the past and we do today.
Honestly, due to that vagueness, it's kind of hard to say how
many of C-Ions are out there,but a few years ago Becker's
released a study of theirs.
They estimated over 500, andthis was a good few years ago.
But, as you can guess, manydon't advertise themselves for
such, and so it's kind of hardto identify the C-Ions out there
(05:48):
and really what they're aboutno-transcript.
Aaron (05:54):
You brought up another little alphabet soup there IPA.
How does a CIN and an IPAdiffer?
Or is it one of thosesituations where there's kind of
a Venn diagram overlay?
Jason (06:13):
Imagine a stair step of collaboration and legal
framework.
IPA is going to be your firststep.
CIN is your natural evolutionto a second step.
Then you have ACOs et cetera,right, and so the difference is
the legal framework, and we'regoing to probably touch on that
quite a bit here.
But within an IPA there isrestrictions in terms of what
(06:36):
you can discuss openly andinformation that can be shared.
Then in the CIN, as a legalentity, once you have that
designation and legal frameworkaround you, you're sort of
covered, if you will, under thatlegal umbrella to have open
conversations with otherproviders outside of your walls.
(06:56):
That you cannot have in an IPA.
So to your point, yes, IPA'sare typically more managed care,
contract, fee for schedule sortof focus.
CIN is going to be a little bitmore value-based care oriented,
you know, working withemployers, things of that nature
.
So there's a definite legalstructure that differentiates
the two, structure thatdifferentiates the two.
Aaron (07:17):
So you know obviously we're SHP.
One of the services that weoffer is SCI and management and
development.
How did SHP start playing inthat space?
Jason (07:32):
Yeah, so around 2013-ish 2014, we had an IPA client of
ours.
It had roughly 25 independentspecialty-based groups, right,
and they're in a market that didnot have a value-based care
present.
So one of the physicians,literally, were sitting in a
(07:53):
board meeting and they broughtit up like guys, how can we
collectively move towardsvalue-based care as a group?
Number one?
Number two there was a lot ofemployment pressures at the time
, as is common when you havemultiple health systems in a
particular market, and they werefeeling that employment
pressure from the health systemcompetition taking place, and so
(08:16):
, from those two points is wherethat particular board of
physicians brought up let's lookinto perhaps clinically
integrated networks.
And I'll say when we're sittingthere around the table and I
can remember this, no one knewanything more than simply what
CIN stood for, and so we knewright away we were going to have
this long process of duediligence, and so a few of us
(08:39):
within the SHB split up theduties, went off for about nine
or 10 months during this duediligence and came out creating
a separate LLC for the samegroup.
That way the members could say,yes, I want to be in both.
No, I just want to be stayingin the IPA, but it allowed them
to have a different entity inwhich it could serve the purpose
(09:00):
of a CIN, right?
But the IPA was a maturedorganization, matured contract
portfolio, and so they felt theCIN needed to stay on its own
for sake of the missions focus,the recruitment, information
sharing, all that kind of thing.
And so my role there wasgeneral research on just CINs, a
(09:22):
provider engagement, arecruitment into the CIN.
And so you go back 2013, 2014,.
For those listening and starteddoing research, there were four
FTC approved CINs in thecountry, and so my first task
was reading through those funlegal documents, right, and so
25, 30 page PDFs by the FTC onthose four CIN reviews, which
(09:46):
was actually very helpful.
And then I started to reach outand interview two of those to
kind of listen to theirsuccesses, their failures and
just overall sort ofrecommendations to us as a
launching that that venture, um.
So since then, after that CIand we, we've launched several
others, um that range fromcreating CINs from scratch to a
(10:11):
single provider group thatreached out about.
We took existing IPAs, such asthat one, evolved them to CINs,
and we took and PHOs thatsubsequently launched CINs and
so they take different formatsand we've been able to manage
those over the years, and so wehave several now that we manage
(10:34):
that are IPA focused and someare PHO focused.
What we've seen is the coreprinciples remain the same,
right, and the reasons folkswant to get into the CINs, the
obstacles they've generally beenthe same, regardless of the
market, regardless of theprovider types or the provider
settings.
We've done them now.
(10:55):
We've got CINs in urban markets, we've got them in rural
markets, we've got them in theSouth, we've got them in the
South, we've got them in theMidwest.
And when we reflect on those,it's kind of surprising how
similar the conversations arewithin each of those same
barriers, same mission, thatsort of thing.
And so, and I'll say, while wewere a little hesitant at first
(11:17):
and we still sometimes are alittle bit more restrictive on
what to take on, we feel thatour success as managers of IPAs
right, and so that includes ourservices around provider
enrollment, managed care,contracting or analytics group,
those types of things naturallytransition to managing CINs, not
(11:40):
to mention just one of ourgoals as a company is to kind of
stay tip of the sword from amarket dynamic standpoint, right
, what's going on, how can welearn, how can we stay ahead of
the curve to be good consultantsto our clients?
And the CIN really allowed usto do that and I think, makes us
(12:01):
better consultants in general.
So yeah, fast forward.
Now here we are, eight yearslater.
Again, we've got several CINsin different markets, and I
think we're just better off forit.
Aaron (12:11):
You know SHP has really been on on the forefront.
Jason (12:14):
It sounds like if if CINs are still relatively within the
last decade or so invention,shp has really been there since
get-go it sounds like we try tolearn from our clients as much
as they try to learn from us,and I think it allows us to
apply those principlesregardless of the market, and
(12:37):
it's also just an advantageoussort of venture by the providers
themselves, which is exactlywhy we're in the game, right.
Aaron (12:46):
Right.
Also, obviously, SHP lowers theramp, or at least makes it
easier for a provider orpractice to form or join a CIN.
But where does one begin?
Is it just, you know, pick upthe phone and call SHP or SHP
aside?
Where does someone who wants togo into the alphabet soup?
(13:09):
Where do they start?
Jason (13:12):
Yeah, great question.
Before you even call us.
I would a couple of things.
Number one appreciate patience,because the education and due
diligence to simply think aboutand launching this initially
does will take several months ata minimum.
So acknowledge the fact thatthis is not going to happen next
month or the next quarter, andmost likely will be closer to
(13:34):
the next year before it's up andgoing.
So be patient.
Second, educate yourself.
There's an abundance of materialout there about CINs, both good
, bad and the ugly right, and so, as I mentioned before, there's
hundreds of CIN's.
Reach out to them.
There's consultants like us onthis webinar.
So so do your homework.
(13:58):
First, the materials out thereum free to be educated, um, and
it'll help you craft yourmessage as well to your peers In
the community, which I wouldsay is sort of the next step.
So you do your homework.
Once you feel prepared, engagewith your peers, with other
providers, other administratorsin that market in your community
.
Discuss your concerns, yourobjectives behind it, why you're
(14:21):
thinking of a CIN.
Essentially, you're going totalk through your why with your
peers.
That dialogue is going to helpyou fine-tune the mission or the
scope of sorts.
It will also kind of simplystart your due diligence process
for you right.
So having such a group from thestart will provide insight and
feedback to you, because youcan't do it alone.
(14:43):
Eventually, those sameindividuals will be your
champions.
They're going to be your boardmembers, they're going to be
your executive committee.
They're going to help youlaunch the entity in the first
place successfully.
So don't go about it on your own.
Engage your peers.
So fast forward.
Now you've got your peers,you're educated, you've got a
(15:04):
grasp of your objectives.
Your partners Find legalcounsel.
Don't go out trying to getcontracts.
Don't buy any platforms.
Engage legal counsel.
Yes, this will beunquestionably your largest
expense for the first full year,but it's worth every penny.
And, as I communicate to folks,there's two swim lanes with CI
(15:27):
and success legal andoperational.
Start with legal.
Okay, first of all, they'llhelp you refine those objectives
.
I mentioned the mission behindthe venture.
The discussion, also with yourcounsel, will transition
naturally to what a successfuloperational game plan looks like
.
And also, once you have thatlegal conversation, you're going
(15:50):
to get a better idea of thebudget Right, we see it so often
that when push comes to shove,the budget is the biggest
obstacle for the CI and the moveforward successfully, and so
once you have that conversation,you'll be able to better have
those projections early onestablishing with that peer
group I just mentioned.
(16:10):
Get comfortable with the legalframework you're having, the
budget you're having, and nowyou can start taking off from.
Okay, what do we need to dooperationally to accomplish the
mission we've been discussingthus far and that's where your
operational gameplay comes in.
But those would be my firstcouple of steps.
Mission we've been discussingthus far and that's where your
operational gameplay comes in.
But those would be my firstcouple of steps.
Educate yourself, engage yourpeers and talk to legal counsel
(16:33):
from the get-go.
That's my first three tips.
Aaron (16:37):
Well, actually I think that leads to another question
what sort of legal counsel?
Obviously there's a lot oflawyers out there.
I think the local Savannahmarket has one lawyer for every
half person, it seems.
So what sort of attorney wouldthey be looking for?
(16:57):
Business healthcare whattypically have you seen been the
most successful for CINs to use?
Jason (17:07):
Yeah, those that have worked with other healthcare
networks, healthcare plans, anyof those with we've worked, some
that have recently left the FTCthemselves.
Um and so those that are usedto M&A activity, collusionary
type or collusion-based sort ofactivity they're going to be
(17:27):
most advantageous for you.
They're going to be the onesthat can best identify those red
flags to be aware of and theyare going to be focused on
things like market shareproviders, appropriate
compliance right.
When a provider's out ofcompliance, do you have a
mechanism in place?
They're going to be focused onthat.
So, those that have thatposition-based background around
(17:51):
M&A, in particular,inclusion-based activity,
oftentimes it's going to be alarger group.
It's going to be hard to find alaw practice with two or three
attorneys that have that sort ofexperience.
So you might get one that'sleft the FTC recent and they're
on their own, but oftentimes itis going to be the larger group
(18:13):
and, yes, they're going to be alarge hourly uh refugiate as
well, but definitely worth it.
Aaron (18:21):
Yeah, yeah, no doubt.
Okay, I know we're we'rerunning out of time here, so, uh
, time here, so we'll get to thelast couple of questions.
So, as the CINs continue tomature again, it's kind of that
newer thing within the lastdecade or so it feels like that
(18:42):
there's new goalposts that havebeen formed.
So you know, what can a new CINexpect to see as those
goalposts being today, and howcan they measure their success
against those key metrics?
Jason (18:58):
Yeah, yeah, so I try to emphasize a few pillars, if you
will right.
So, be focused on appropriateand engaged governance structure
, a data information strategy,one that's flexible and not
(19:26):
focused on one carrier or planor mechanism.
And so, as you talk through howto measure your success and
metrics, it kind of falls underthose key pillars that I've just
mentioned, and you want toseparate those because you'll
need different folks andchampions within each of those
right and so, and when I talkabout product deployment, for
example, be mindful of operate,though, because you'll need
different folks and championswithin each of those right and
so, and when I talk aboutproduct deployment, for example,
(19:48):
be mindful of things likedirect to employer agreements.
Don't be so focused on just oh,I got to get my particular
carrier plan up, or things ofthat nature.
Start looking at MA plans aswell as commercial plans.
Everything should be on yourradar as far as a product
deployment.
But to get a little bit moregranular, question a couple of
those pillars I mentioned.
(20:10):
Governance, for example.
Right, your board is oftencomprised of physicians and
administrators.
Your executive committee istypically administrator driven,
and then that next group ofindividuals you've got to launch
is a QA committee.
That is vital.
That's going to come up in thefirst 15 minutes with your legal
counsel.
There are others you can launchas well, right, finance and
(20:31):
contracting committee, itcommittee, et cetera.
But start with those three yourboard, your executive committee
, your QA committee.
We won't get into that, that'sa whole other episode of it in
and of itself.
And then data Again, that willcome up as well in the first 15
minutes of legal counsel.
You absolutely must have someform of information sharing as a
(20:53):
CIN, preferably in aprovider-led QA committee, right
, and so just focus on that justfor a second.
Oftentimes you'll hear that aCIN is going to have a popular
platform.
Okay, first of all, be preparedfor the sticker shot there.
Now just, are you required tohave a platform?
No, okay, we'll get onto thatin a second.
(21:13):
But pop health platforms arevery expensive, not just
themselves, but every tax IDthat has to get with their EMR
vendor, and they have to developan interface.
That's expensive.
There's maintenance plans there, and so don't just stop there.
There's other paths to successfrom that legal checkbox that
has to be met with data, right,there's HIE options, health
(21:36):
information exchange options.
They're often less expensive.
Folks are often alreadysubmitting data, most
importantly the hospitals, andthey're getting better from a
reporting perspective.
Another option in the favoriteof mine is work with your TPAs,
your carriers, your employers.
Oftentimes they've got tools inplace and they've got specific
(21:57):
programs they want to focus onand work with you so therefore
they can supply information toyou so you're not even have to
worry about the costs or theresources it takes to store that
information.
I'll give you a very specificexample.
We have a PHO that's a CI andthey launched its QA committee
solely with one large employer.
(22:19):
A TPA supplies two or three PDFreports every month.
That QA committee now knowsthey have to review those
reports for that one employer inthe discussions around areas of
impregnation.
Okay, and that helps yourgovernance structure that I
mentioned before, because thatcommittee needs to be in place
(22:40):
and comprised of employee docs,independent docs, different
specialties place, and comprisedof employee docs, independent
docs, different specialties,things of that nature, and
you're able to document theminutes of that committee.
So you see the sort of you knowstair-step benefits of working
with the TPA, for example, andlaunching the QA committee
because you've got to documentminutes for that committee.
(23:01):
Your legal counsel is going toask you that, and there's a ton
more we can get into withgovernance, like compliance
plans, things of that committeeyour legal counsel is going to
ask you that and there's a tonmore we can get into with
governance, like complianceplans, things of that nature,
but proper credentialingpolicies and procedures,
communication, things like that.
But yeah, the key success isbeing around proper governance
structure, then the informationsharing that goes along with it.
Aaron (23:21):
To dovetail a little bit about PopHealth tools and those
other analytical tools.
You know, obviously we have QPP, we have the Quality Payment
Program and all the ways toparticipate in that.
Do you see CINs as a way toparticipate in QPP using those
sort of tools in QPP?
Jason (23:42):
using those sort of tools .
Oh, absolutely, I think,whether it's QPP.
We've got a client that was anIPA that became a CIN and they
became a CIN so that they canget into an ACO and be a more
successful ACO.
So the CIN was sort of a prepwork to be a successful ACO for
engaging in that contract,successful ACO for engaging in
(24:04):
that contract.
And so I would take the sameand apply it to QPP in that, in
that that group can collectivelywork together, brainstorm
together.
And that's another benefit ofthe CIN is simply the networking
with your peers of what toolsdo you use, what resources do
you have.
They can become their smallgroup in terms of gathering the
data necessary and submittingright, and I'll default to
(24:26):
Aaron's QPP podcast on that.
I'm getting in the weeds there.
But again, the collectivenature of a CIN and the
education and networking aroundit will also benefit you in your
QPP venture.
So, yes, I would definitelyagree with that, okay.
Aaron (24:43):
Well, thank you, jason.
I know we're coming right up ontime.
So if folks want to learn moreabout CINs you know how to form
one or how to participate in onehow can they get in touch with
you?
Jason (24:56):
Yeah, so feel free to give me an email, jcrosby@shpllc
.
com.
Let's schedule a call.
We typically just talk throughwith you.
I've got some key questions andvarious documents that serve as
a template just to help getyour mind thinking along those
lines and then you can go offand do your necessary due
(25:18):
diligence.
Yeah, let's set up a good 20 or30-minute call and I think
that'll be of great help to you.
That's great.
Anything else you want to makesure our audience knows about
before we head out?
No, guys, just don't getoverwhelmed.
It's just like when you guyshad implemented EMRs and MIPS
came out.
There's an overwhelming feelingbecause of the amount of
(25:42):
information out there.
Simplify it.
It's not as complex as it'sgoing to feel when you're
reading, but just simplify itand be patient and give folks
like myself a call.
We'll help walk you through it.
Aaron (25:50):
All right, well, hey, thank you, jason, for your time
today.
Now you got a busy schedule, sothanks for clearing a few
minutes for us to talk.
Jason (25:57):
Appreciate it, Aaron.
Thank you and thanks foreverybody for listening.
Aaron (26:02):
You've been listening to Beyond the Stethoscope vital
conversations with shp.
This has been a production ofstrategic health care partners,
your news host today, for jasoncrosby and me, aaron higgins.
It is produced and edited bynyla weave, our social media
content producers are nyla andjeremy miller and our executive
producers are mike scrivener andjohn crew.
(26:23):
More information.
Thanks for listening.
Welcome to Beyond the Stethoscope Vital Conversations
with SHP.
As we take our summer break toprepare for the exciting Season
5, we're revisiting some of ourmost insightful episodes to keep
the conversation going.
In this episode, originallyaired all the way back in Season
1, we explore the fascinatingjourney of building a healthcare
network from the ground up.
Jason Crosby, our residenthealthcare expert with over 25
(00:30):
years of experience, joins us todive deep into the world of
clinically integrated networks,or CINs.
From the challenges ofvalue-based care to the legal
intricacies of forming a CIN,jason shares his extensive
knowledge and experience.
So, whether you're a healthcareprofessional or simply curious
about the inner workings of thisvital industry, this episode
offered a unique glimpse intothe evolution of healthcare
(00:52):
networks.
Don't miss this opportunity torevisit an essential
conversation that remainsrelevant today and, as always,
if you find this episode helpful, please rate and share our
podcast in your favorite podcastapp.
It really helps us reach morelisteners.
Let's join Jason Crosby andmyself as he takes us behind the
scenes of CINs.
Jason (01:17):
Hey, good morning Aaron, Good morning everybody.
Good to be here.
Aaron (01:20):
Yeah, alrighty.
Well, we are here today with,actually, what should be a
fairly familiar voice is JasonCrosby.
You may have heard him doingsome interviews as well, and so
we're going to talk, though, notabout how to do a podcast, but
some of the other things thatJason is well versed in, and so,
(01:44):
I guess, help us understandJason.
You know what, what is yourbackground, you know what, what
makes you a vital conversation.
Jason (01:53):
So my first taste of healthcare came about 25 years
ago actually, during kind of anundergraduate internship at a
local health system with acouple of different units in the
hospital, and from there I wasjust hooked and so fast forward
a few years, went through gradschool all that it's my first
air quotes.
(02:14):
Real job was an entry-leveldescent support analyst at a
different health system, Wasthere for several years in
descent support and IT, did theproject management thing, did
the Six Sigma and ended upmanager of decision support,
which was my first managementgig and probably still to this
(02:36):
day one of my favorite jobs.
I really enjoyed that Leftthere, became finance director
for a large ER physician groupand then came to SHP about 13
years ago and so, honestly, thewhich, looking back the health
system and the practice settings, really, I would say, helped me
(02:58):
greatly coming into aconsulting world you know,
wearing multiple hats and tryingto be all things in all
settings and so that's, that'skind of been the journey.
Aaron (03:10):
Wow, yeah, you kind of run the gamut of health care
types too.
You know the hospital world tothe practice world and now the
consulting world.
So I know one of thespecialties that you deal with
within SHP are are CINs.
Tell me a little bit aboutthose for those in the audience
(03:32):
that may not be familiar withwhat a CIN is, and you know how.
How are you engaged with that?
Jason (03:39):
Yes, let's.
Let's get ready for athree-letter alphabet soup here.
Um, cin, a clinicallyintegrated network.
So go back about 25 years, 30years or so, the FTC came in and
the Federal Trade Commissionestablished their formal
definition.
And not to bore everybody withwhat that is, but it highlighted
(04:01):
some key words that areapplicable to everybody,
listening today, right, andexist in another form of CI
definitions Independence,cooperation, collaboration,
modifying practice patterns,controlling cost, improving
quality those same things wehear about today that are still
(04:22):
a consistent sort of basis or atheme that providers work from
today.
But in essence, a CIN is simplyas a clinically ingrained
network, even though it's gotmany definitions, it's its own
legal entity.
It's comprised of multipleorganizations, including
providers, physicians, healthsystem, age layer groups, et
(04:42):
cetera.
That basically it's intended toachieve what we now know and
call the AAA and principle ofhealthcare, right?
So these entities, they take onvarious forms, various modes of
evolution, the most typicalbeing your PHO, just adding
another three-letter acronym outthere Physician Hospital
(05:04):
Organization, type of entitywhere you have a hospital
alongside their employedphysicians, sometimes the
community independent providers.
The other common form we see isa collection of independent docs
or an IPA.
You know each of which we'veworked with in the past and we
do today.
So we're an IPA, you know eachof which we've worked with in
(05:26):
the past and we do today.
Honestly, due to that vagueness, it's kind of hard to say how
many of C-Ions are out there,but a few years ago Becker's
released a study of theirs.
They estimated over 500, andthis was a good few years ago.
But, as you can guess, manydon't advertise themselves for
such, and so it's kind of hardto identify the C-Ions out there
(05:48):
and really what they're aboutno-transcript.
Aaron (05:54):
You brought up another little alphabet soup there IPA.
How does a CIN and an IPAdiffer?
Or is it one of thosesituations where there's kind of
a Venn diagram overlay?
Jason (06:13):
Imagine a stair step of collaboration and legal
framework.
IPA is going to be your firststep.
CIN is your natural evolutionto a second step.
Then you have ACOs et cetera,right, and so the difference is
the legal framework, and we'regoing to probably touch on that
quite a bit here.
But within an IPA there isrestrictions in terms of what
(06:36):
you can discuss openly andinformation that can be shared.
Then in the CIN, as a legalentity, once you have that
designation and legal frameworkaround you, you're sort of
covered, if you will, under thatlegal umbrella to have open
conversations with otherproviders outside of your walls.
(06:56):
That you cannot have in an IPA.
So to your point, yes, IPA'sare typically more managed care,
contract, fee for schedule sortof focus.
CIN is going to be a little bitmore value-based care oriented,
you know, working withemployers, things of that nature
.
So there's a definite legalstructure that differentiates
the two, structure thatdifferentiates the two.
Aaron (07:17):
So you know obviously we're SHP.
One of the services that weoffer is SCI and management and
development.
How did SHP start playing inthat space?
Jason (07:32):
Yeah, so around 2013-ish 2014, we had an IPA client of
ours.
It had roughly 25 independentspecialty-based groups, right,
and they're in a market that didnot have a value-based care
present.
So one of the physicians,literally, were sitting in a
(07:53):
board meeting and they broughtit up like guys, how can we
collectively move towardsvalue-based care as a group?
Number one?
Number two there was a lot ofemployment pressures at the time
, as is common when you havemultiple health systems in a
particular market, and they werefeeling that employment
pressure from the health systemcompetition taking place, and so
(08:16):
, from those two points is wherethat particular board of
physicians brought up let's lookinto perhaps clinically
integrated networks.
And I'll say when we're sittingthere around the table and I
can remember this, no one knewanything more than simply what
CIN stood for, and so we knewright away we were going to have
this long process of duediligence, and so a few of us
(08:39):
within the SHB split up theduties, went off for about nine
or 10 months during this duediligence and came out creating
a separate LLC for the samegroup.
That way the members could say,yes, I want to be in both.
No, I just want to be stayingin the IPA, but it allowed them
to have a different entity inwhich it could serve the purpose
(09:00):
of a CIN, right?
But the IPA was a maturedorganization, matured contract
portfolio, and so they felt theCIN needed to stay on its own
for sake of the missions focus,the recruitment, information
sharing, all that kind of thing.
And so my role there wasgeneral research on just CINs, a
(09:22):
provider engagement, arecruitment into the CIN.
And so you go back 2013, 2014,.
For those listening and starteddoing research, there were four
FTC approved CINs in thecountry, and so my first task
was reading through those funlegal documents, right, and so
25, 30 page PDFs by the FTC onthose four CIN reviews, which
(09:46):
was actually very helpful.
And then I started to reach outand interview two of those to
kind of listen to theirsuccesses, their failures and
just overall sort ofrecommendations to us as a
launching that that venture, um.
So since then, after that CIand we, we've launched several
others, um that range fromcreating CINs from scratch to a
(10:11):
single provider group thatreached out about.
We took existing IPAs, such asthat one, evolved them to CINs,
and we took and PHOs thatsubsequently launched CINs and
so they take different formatsand we've been able to manage
those over the years, and so wehave several now that we manage
(10:34):
that are IPA focused and someare PHO focused.
What we've seen is the coreprinciples remain the same,
right, and the reasons folkswant to get into the CINs, the
obstacles they've generally beenthe same, regardless of the
market, regardless of theprovider types or the provider
settings.
We've done them now.
(10:55):
We've got CINs in urban markets, we've got them in rural
markets, we've got them in theSouth, we've got them in the
South, we've got them in theMidwest.
And when we reflect on those,it's kind of surprising how
similar the conversations arewithin each of those same
barriers, same mission, thatsort of thing.
And so, and I'll say, while wewere a little hesitant at first
(11:17):
and we still sometimes are alittle bit more restrictive on
what to take on, we feel thatour success as managers of IPAs
right, and so that includes ourservices around provider
enrollment, managed care,contracting or analytics group,
those types of things naturallytransition to managing CINs, not
(11:40):
to mention just one of ourgoals as a company is to kind of
stay tip of the sword from amarket dynamic standpoint, right
, what's going on, how can welearn, how can we stay ahead of
the curve to be good consultantsto our clients?
And the CIN really allowed usto do that and I think, makes us
(12:01):
better consultants in general.
So yeah, fast forward.
Now here we are, eight yearslater.
Again, we've got several CINsin different markets, and I
think we're just better off forit.
Aaron (12:11):
You know SHP has really been on on the forefront.
Jason (12:14):
It sounds like if if CINs are still relatively within the
last decade or so invention,shp has really been there since
get-go it sounds like we try tolearn from our clients as much
as they try to learn from us,and I think it allows us to
apply those principlesregardless of the market, and
(12:37):
it's also just an advantageoussort of venture by the providers
themselves, which is exactlywhy we're in the game, right.
Aaron (12:46):
Right.
Also, obviously, SHP lowers theramp, or at least makes it
easier for a provider orpractice to form or join a CIN.
But where does one begin?
Is it just, you know, pick upthe phone and call SHP or SHP
aside?
Where does someone who wants togo into the alphabet soup?
(13:09):
Where do they start?
Jason (13:12):
Yeah, great question.
Before you even call us.
I would a couple of things.
Number one appreciate patience,because the education and due
diligence to simply think aboutand launching this initially
does will take several months ata minimum.
So acknowledge the fact thatthis is not going to happen next
month or the next quarter, andmost likely will be closer to
(13:34):
the next year before it's up andgoing.
So be patient.
Second, educate yourself.
There's an abundance of materialout there about CINs, both good
, bad and the ugly right, and so, as I mentioned before, there's
hundreds of CIN's.
Reach out to them.
There's consultants like us onthis webinar.
So so do your homework.
(13:58):
First, the materials out thereum free to be educated, um, and
it'll help you craft yourmessage as well to your peers In
the community, which I wouldsay is sort of the next step.
So you do your homework.
Once you feel prepared, engagewith your peers, with other
providers, other administratorsin that market in your community
.
Discuss your concerns, yourobjectives behind it, why you're
(14:21):
thinking of a CIN.
Essentially, you're going totalk through your why with your
peers.
That dialogue is going to helpyou fine-tune the mission or the
scope of sorts.
It will also kind of simplystart your due diligence process
for you right.
So having such a group from thestart will provide insight and
feedback to you, because youcan't do it alone.
(14:43):
Eventually, those sameindividuals will be your
champions.
They're going to be your boardmembers, they're going to be
your executive committee.
They're going to help youlaunch the entity in the first
place successfully.
So don't go about it on your own.
Engage your peers.
So fast forward.
Now you've got your peers,you're educated, you've got a
(15:04):
grasp of your objectives.
Your partners Find legalcounsel.
Don't go out trying to getcontracts.
Don't buy any platforms.
Engage legal counsel.
Yes, this will beunquestionably your largest
expense for the first full year,but it's worth every penny.
And, as I communicate to folks,there's two swim lanes with CI
(15:27):
and success legal andoperational.
Start with legal.
Okay, first of all, they'llhelp you refine those objectives
.
I mentioned the mission behindthe venture.
The discussion, also with yourcounsel, will transition
naturally to what a successfuloperational game plan looks like
.
And also, once you have thatlegal conversation, you're going
(15:50):
to get a better idea of thebudget Right, we see it so often
that when push comes to shove,the budget is the biggest
obstacle for the CI and the moveforward successfully, and so
once you have that conversation,you'll be able to better have
those projections early onestablishing with that peer
group I just mentioned.
(16:10):
Get comfortable with the legalframework you're having, the
budget you're having, and nowyou can start taking off from.
Okay, what do we need to dooperationally to accomplish the
mission we've been discussingthus far and that's where your
operational gameplay comes in.
But those would be my firstcouple of steps.
Mission we've been discussingthus far and that's where your
operational gameplay comes in.
But those would be my firstcouple of steps.
Educate yourself, engage yourpeers and talk to legal counsel
(16:33):
from the get-go.
That's my first three tips.
Aaron (16:37):
Well, actually I think that leads to another question
what sort of legal counsel?
Obviously there's a lot oflawyers out there.
I think the local Savannahmarket has one lawyer for every
half person, it seems.
So what sort of attorney wouldthey be looking for?
(16:57):
Business healthcare whattypically have you seen been the
most successful for CINs to use?
Jason (17:07):
Yeah, those that have worked with other healthcare
networks, healthcare plans, anyof those with we've worked, some
that have recently left the FTCthemselves.
Um and so those that are usedto M&A activity, collusionary
type or collusion-based sort ofactivity they're going to be
(17:27):
most advantageous for you.
They're going to be the onesthat can best identify those red
flags to be aware of and theyare going to be focused on
things like market shareproviders, appropriate
compliance right.
When a provider's out ofcompliance, do you have a
mechanism in place?
They're going to be focused onthat.
So, those that have thatposition-based background around
(17:51):
M&A, in particular,inclusion-based activity,
oftentimes it's going to be alarger group.
It's going to be hard to find alaw practice with two or three
attorneys that have that sort ofexperience.
So you might get one that'sleft the FTC recent and they're
on their own, but oftentimes itis going to be the larger group
(18:13):
and, yes, they're going to be alarge hourly uh refugiate as
well, but definitely worth it.
Aaron (18:21):
Yeah, yeah, no doubt.
Okay, I know we're we'rerunning out of time here, so, uh
, time here, so we'll get to thelast couple of questions.
So, as the CINs continue tomature again, it's kind of that
newer thing within the lastdecade or so it feels like that
(18:42):
there's new goalposts that havebeen formed.
So you know, what can a new CINexpect to see as those
goalposts being today, and howcan they measure their success
against those key metrics?
Jason (18:58):
Yeah, yeah, so I try to emphasize a few pillars, if you
will right.
So, be focused on appropriateand engaged governance structure
, a data information strategy,one that's flexible and not
(19:26):
focused on one carrier or planor mechanism.
And so, as you talk through howto measure your success and
metrics, it kind of falls underthose key pillars that I've just
mentioned, and you want toseparate those because you'll
need different folks andchampions within each of those
right and so, and when I talkabout product deployment, for
example, be mindful of operate,though, because you'll need
different folks and championswithin each of those right and
so, and when I talk aboutproduct deployment, for example,
(19:48):
be mindful of things likedirect to employer agreements.
Don't be so focused on just oh,I got to get my particular
carrier plan up, or things ofthat nature.
Start looking at MA plans aswell as commercial plans.
Everything should be on yourradar as far as a product
deployment.
But to get a little bit moregranular, question a couple of
those pillars I mentioned.
(20:10):
Governance, for example.
Right, your board is oftencomprised of physicians and
administrators.
Your executive committee istypically administrator driven,
and then that next group ofindividuals you've got to launch
is a QA committee.
That is vital.
That's going to come up in thefirst 15 minutes with your legal
counsel.
There are others you can launchas well, right, finance and
(20:31):
contracting committee, itcommittee, et cetera.
But start with those three yourboard, your executive committee
, your QA committee.
We won't get into that, that'sa whole other episode of it in
and of itself.
And then data Again, that willcome up as well in the first 15
minutes of legal counsel.
You absolutely must have someform of information sharing as a
(20:53):
CIN, preferably in aprovider-led QA committee, right
, and so just focus on that justfor a second.
Oftentimes you'll hear that aCIN is going to have a popular
platform.
Okay, first of all, be preparedfor the sticker shot there.
Now just, are you required tohave a platform?
No, okay, we'll get onto thatin a second.
(21:13):
But pop health platforms arevery expensive, not just
themselves, but every tax IDthat has to get with their EMR
vendor, and they have to developan interface.
That's expensive.
There's maintenance plans there, and so don't just stop there.
There's other paths to successfrom that legal checkbox that
has to be met with data, right,there's HIE options, health
(21:36):
information exchange options.
They're often less expensive.
Folks are often alreadysubmitting data, most
importantly the hospitals, andthey're getting better from a
reporting perspective.
Another option in the favoriteof mine is work with your TPAs,
your carriers, your employers.
Oftentimes they've got tools inplace and they've got specific
(21:57):
programs they want to focus onand work with you so therefore
they can supply information toyou so you're not even have to
worry about the costs or theresources it takes to store that
information.
I'll give you a very specificexample.
We have a PHO that's a CI andthey launched its QA committee
solely with one large employer.
(22:19):
A TPA supplies two or three PDFreports every month.
That QA committee now knowsthey have to review those
reports for that one employer inthe discussions around areas of
impregnation.
Okay, and that helps yourgovernance structure that I
mentioned before, because thatcommittee needs to be in place
(22:40):
and comprised of employee docs,independent docs, different
specialties place, and comprisedof employee docs, independent
docs, different specialties,things of that nature, and
you're able to document theminutes of that committee.
So you see the sort of you knowstair-step benefits of working
with the TPA, for example, andlaunching the QA committee
because you've got to documentminutes for that committee.
(23:01):
Your legal counsel is going toask you that, and there's a ton
more we can get into withgovernance, like compliance
plans, things of that committeeyour legal counsel is going to
ask you that and there's a tonmore we can get into with
governance, like complianceplans, things of that nature,
but proper credentialingpolicies and procedures,
communication, things like that.
But yeah, the key success isbeing around proper governance
structure, then the informationsharing that goes along with it.
Aaron (23:21):
To dovetail a little bit about PopHealth tools and those
other analytical tools.
You know, obviously we have QPP, we have the Quality Payment
Program and all the ways toparticipate in that.
Do you see CINs as a way toparticipate in QPP using those
sort of tools in QPP?
Jason (23:42):
using those sort of tools .
Oh, absolutely, I think,whether it's QPP.
We've got a client that was anIPA that became a CIN and they
became a CIN so that they canget into an ACO and be a more
successful ACO.
So the CIN was sort of a prepwork to be a successful ACO for
engaging in that contract,successful ACO for engaging in
(24:04):
that contract.
And so I would take the sameand apply it to QPP in that, in
that that group can collectivelywork together, brainstorm
together.
And that's another benefit ofthe CIN is simply the networking
with your peers of what toolsdo you use, what resources do
you have.
They can become their smallgroup in terms of gathering the
data necessary and submittingright, and I'll default to
(24:26):
Aaron's QPP podcast on that.
I'm getting in the weeds there.
But again, the collectivenature of a CIN and the
education and networking aroundit will also benefit you in your
QPP venture.
So, yes, I would definitelyagree with that, okay.
Aaron (24:43):
Well, thank you, jason.
I know we're coming right up ontime.
So if folks want to learn moreabout CINs you know how to form
one or how to participate in onehow can they get in touch with
you?
Jason (24:56):
Yeah, so feel free to give me an email, jcrosby@shpllc
.
com.
Let's schedule a call.
We typically just talk throughwith you.
I've got some key questions andvarious documents that serve as
a template just to help getyour mind thinking along those
lines and then you can go offand do your necessary due
(25:18):
diligence.
Yeah, let's set up a good 20 or30-minute call and I think
that'll be of great help to you.
That's great.
Anything else you want to makesure our audience knows about
before we head out?
No, guys, just don't getoverwhelmed.
It's just like when you guyshad implemented EMRs and MIPS
came out.
There's an overwhelming feelingbecause of the amount of
(25:42):
information out there.
Simplify it.
It's not as complex as it'sgoing to feel when you're
reading, but just simplify itand be patient and give folks
like myself a call.
We'll help walk you through it.
Aaron (25:50):
All right, well, hey, thank you, jason, for your time
today.
Now you got a busy schedule, sothanks for clearing a few
minutes for us to talk.
Jason (25:57):
Appreciate it, Aaron.
Thank you and thanks foreverybody for listening.
Aaron (26:02):
You've been listening to Beyond the Stethoscope vital
conversations with shp.
This has been a production ofstrategic health care partners,
your news host today, for jasoncrosby and me, aaron higgins.
It is produced and edited bynyla weave, our social media
content producers are nyla andjeremy miller and our executive
producers are mike scrivener andjohn crew.
(26:23):
More information.
Thanks for listening.
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