Revisit: Keys to a Successful CIN | With Jason Crosby

In this episode, Jason shares with us the results of a study that shows PCPs may be unfairly punished with poor MIPS scores. Aaron shares a warning about two different crypto viruses targeting healthcare organizations. And we briefly discuss our upcoming season 2.

Then, 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. 

Aaron’s News
https://www.hhs.gov/sites/default/files/lockbit-3-analyst-note.pdf

https://www.hhs.gov/sites/default/files/blackcat-analyst-note.pdf

Jason’s News

Value-based payment system shortchanges PCPs, says study (fiercehealthcare.com)

Transcript 

Credits

Production Assistance & Editing: Nyla Wiebe

Scripting by: Aaron C Higgins

Show Notes & Transcription: Aaron C Higgins

Social Media Management: Jeremy Miller & Nyla Wiebe

News Co-Hosts: Aaron C Higgins & Jason Crosby

Interview hosts: Aaron C Higgins

Executive Producers: Mike Scribner & John Crew

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Transcript

Aaron: 0:50

Welcome to the last episode of season 1 of Beyond the Stethoscope Vital Conversations with SHP. In this episode, jason shares with us the results of a study that shows PCPs may be unfairly punished with poor MIP scores. I share a warning about two different crypto viruses targeting healthcare organizations and we briefly discuss our upcoming season 2. And then I sit 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 ultimately help provide value-based care. Are you ready for this vital conversation? Let's get started.

Jason: 1:41

Good morning Aaron. How are?

Aaron: 1:42

you today? I'm doing pretty good, Jason. How about you? Fantastic.

Jason: 1:46

We are here in the holiday season. Today is our last of 2022, as far as our podcast interviews, so excited to kick this one off.

Aaron: 2:00

It's been a fun trip during the last 10 weeks here. It has. It's been exciting, learned a lot.

Jason: 2:06

We certainly hope our listeners have as well. But let's go ahead and get this started. I know a lot in the news today. What have you found interesting?

Aaron: 2:15

I found this really fascinating. So this is actually going to tie into a topic we're going to talk about next season, and that's ransomware. So there have been two back-to-back warnings from HHS through what they call the Health Sector Cybersecurity Coordination Center, or HC3. And they've issued two warnings. One is for a Blackcat ransomware variant that is running rampant and is a successor of several other very successful cyberattacks that have happened specifically targeting healthcare organizations. So Blackcat ransomware. And then the other is another called LockBit 3.0. Now, obviously this is 3.0, which means there was a 2.0 and a 1.0. So LockBit 3.0 is also targeting the healthcare industry, because they know that there isa lot of weaknesses there. It and healthcare is generally underfunded.

Aaron: 3:15

So this one, though, at LockBit, is what they're calling a triple threat. So they extort you three different ways. They encrypt your network and they extort you that way, then they blackmail you with the data, and so you have to pay them off, and then to get them to destroy the data, you also have to pay them. So it is that one they're calling a triple threat. It's definitely a financially motivated ransomware, and a lot of times we find that these criminal organizations are usually state led. So Russia, north Korea, china. Those are usually the entities behind these criminal organizations. It's a way for them to raise money and have it not be traceable to them. So be on the lookout for this. We're going to have a whole episode about how to better protect your organization against these kind of threats. So, jason, what headlines do you have for us?

Jason: 4:17

Yeah, well, piggybacking your podcast and webinar of late, and that is around MIPS. The Journal for the American Medical Association, jama, released a study of over 80,000 primary care physicians in particular to the 2019 performance year for MIPS, and the theory was okay, what is the correlation of primary care quality and outcomes as it pertains to their MIPS scores? And what they found was that the MIPS scores were inconsistent, related to performance on process and outcomes measures, and so, therefore, were primary care physicians being unfairly penalized when it came to MIPS for their more medically complex sort of patient load? Right, and so very interesting results where they saw on both ends of the pendulum there, nearly 5,000 of those received very low MIPS scores, but then there were some that received high MIPS scores, but there was correlation of those that had significantly lower HB81C screening, diabetic eye examinations, things of that nature, and so there was some correlation to tie that. Yes, maybe some are unfairly penalized, but that's okay and this is to help as a journey, and so this is just more data to tell us where we are currently and, hopefully, some modifications there.

Jason: 5:38

What also found interesting was out of those 80,000, which was over 4 million lives, by the way so the 80,000 physicians, 4 million lives worth of data was also the fact that in 2019, practices spent more than $12,000 per PCP to just participate in MIPS, and so we do a law rule providers out there saying no practices.

Jason: 6:01

That's not a drop in the bucket, that's a substantial amount, and so there's concern is such resources exasperating health inequities by transferring those resources away from other needs? So there's again, the data is there to kind of spur further conversations, right, and the point is MIPS isn't bad or good or this evil thing. It's part of the journey on maybe how it can evolve. So a very informative outcome of a study done based on the 2019 results and we'll see. Knowing that again, the adjustments as you mentioned in your podcast here, the 9% plus or minus penalties coming up soon, and so now MIPS is a big deal to your bottom line and there's more data to show where you should go with that if you're a practice now. So found that interesting, but that's my story for the week.

Aaron: 6:50

Okay, jason. Well, just a quick teaser for the audience. This is the end of season one for us. We'll be picking up again in late winter, so probably in the February timeframe We'll have more episodes. We're changing up the format a little bit. We're really excited on on some of these changes that we'll be rolling out in in February. So stay tuned for an announcement about season two. So, jason, who is our interview today?

Jason: 7:22

Well, if there was ever more truth to the saying, we save the best for last. This is it. People, I had the pleasure of being interviewed by yourself and we're talking today about clinically integrated network CINs. What is that? What are they used for? Should you join it? How do you join it? How are you successful with CINs? So we're going to dive in deep to the operational aspects of CIN strategy, legal and that kind of thing.

Aaron: 7:50

An exhilarating podcast, I would say I'm looking forward to listening to it, but I was there when we recorded it, so I hope everybody does enjoy listening to it. Everyone have a very merry Christmas, a happy holiday season and a happy new year, and we'll catch you all next year. Well, hey there. Good morning, Jason. How are you doing today?

Jason: 8:18

Hey, good morning Aaron, Good morning everybody. Good to be here.

Aaron: 8:22

Well, we are here today with actually what should be a fairly familiar voice, is Jason Crosby. You may have heard him doing some interviews as well, and so we're going to talk, though, not about how to do a podcast, but some of the other things that Jason is well versed in, and so, I guess, help us understand Jason. What is your background? What makes you a vital

Jason: 8:54

So my first taste of healthcare came about 25 years ago actually, during kind of an undergraduate internship at a local health system with a couple of different units in the hospital, and from there I was just hooked and so fast forward a few years, went through grad school, all that. So my first air quotes real job was an entry level decnt support analyst at a ifferent health system. I was there for several years in decent support and IT, did the project management thing, did the six segment ended up major decent support, which was my first management gig and probably still this day one of my favorite jobs. Really enjoyed that. That left there, became finest director for a large ER physician group, and then came the SHP about 13 years ago and so honestly though, which, looking back the health system and the practice settings really would say, helped me greatly coming into a consulting world, you know, wearing multiple hats and trying to be all things in all settings, and so that's, that's kind of been the journey.

Aaron: 10:10

Well, yeah, you kind of run the gamut of healthcare types too, the hospital world to the practice world and now consulting world. So I know one of the specialties that you deal with within SHP are our CINs. Tell me a little bit about those for those in audience that may not be familiar with what a CIN is and you know how. How are you engaged with that?

Jason: 10:40

Let's get ready for a three letter alphabet soup here. Cin, a Clinically integrated network. So go back about 25 years, 30 years or so. The FTC came in and that's the Federal Trade Commission established their formal definition, and not to bore everybody with what that is, but it highlighted some key words that are applicable to everybody, listening today, right, and exist in another form of CIN definitions Independence, cooperation, collaboration, modifying practice patterns, controlling cost, improving quality those same things we hear about today that are still a consistent sort of basis or a theme that providers work from today.

Jason: 11:28

But in essence, the CIN is simply a clinically integrated network, even though it's got many definitions, is its own legal entity. It's comprised of multiple organizations, including providers, physicians, health system, etc. That basically it's intended to achieve what we now know and call the aim of healthcare right. So these entities, they take on various forms, various modes of evolution, the most typical being your PHO. Just add another three-letter acronym out there a physician hospital organization type of entity where you have a hospital alongside their employed physicians.

Jason: 12:13

The community independent providers. The other common form we see is a collection of independent docs or an IPA, each of which we've worked with in the past and we do today. Honestly, due to that vagueness, it's kind of hard to say how many of CINs are out there, but a few years ago Becker's released a study of theirs. They estimated over 500, and this is a good few years ago. But, as you can guess, many don't advertise themselves for such and so it's kind of hard to identify the CINs out there and really what they're about. But in essence, that's what a CIN is.

Aaron: 12:55

You brought up another little alphabet soups there IPA. How does a CIN and an IPA differ? Or is it one of those situations where there's kind of a Venn diagram over layout both yeah?

Jason: 13:12

Great follow-up. There's independent physician association. Imagine a stair step of collaboration a legal framework. Ipa is going to be your first step. Cin is your natural evolution to a second step. Then you have ACOs, etc. Right, and so the difference is the legal framework and we're going to probably touch on that quite a bit here. But within an IPA there is restrictions in terms of what you can discuss openly and information that can be shared. Then in CIN, as a legal entity, once you have that designation and legal framework around you, you're sort of covered, if you will, under that legal umbrella to have open conversations with other providers outside of your walls. That you cannot have in an IPA. So to your point, yes, IPAs are typically more of managed care, contract, fee for schedule sort of focus. Cin is going to be a little bit more value-based care oriented, working with employers, things of that nature. So there's a definite legal structure that differentiates the two.

Aaron: 14:22

One of the services that we offer is CIN management and development. How did SHP start playing in that space?

Jason: 14:33

Yeah, so around 2013-ish 2014, we had an IPA client of ours. We had roughly 25 independent specialty-based groups right, and they are in a market that did not have a value-based care present. So one of the physicians literally was sitting in a board meeting and they brought it up Like guys, how can we collectively move towards value-based care as a group? There was a lot of employment pressures at the time, as is common when you have multiple health systems in a particular market, and they were feeling that employment pressure from the health system competition taking place, and so, from those two points is where that particular board of physicians brought up let's look into perhaps clinically integrating networks. And I'll say when we're sitting there around the table and I can remember this, no one knew anything more than simply what CIN stood for, and so we knew right away we were going to have this long process of due diligence, and so a few of us within SHP split up the duties, went off for about nine or ten months during this due diligence and came out creating a separate LLC for the same group. That way the members could say, yes, I want to be in both. No, I just want to be staying in the IPA but allowed them to have a different entity in which could serve the purpose of a CIN. The IPA was a mature organization, matured contract portfolio, and so they felt the CIN needed to stand alone for sake of the mission's focus, the recruitment, information sharing, all that kind of thing. And so my role there was general research on just CINs, the provider engagement, recruitment into the CIN. And so you go back 2013, 2014, for those listening and start doing research. There were four FTC approved CINs in the country, and so my first task was reading through those fun legal documents, right, and so 25, 30 page PDFs by the FTC on those four CIN reviews, which was actually very helpful. And then I started to reach out and interview two of those to kind of listen to their successes, their failures and just overall sort of recommendations to us as a launching that that venture.

Jason: 17:02

So since then, after that CIN, we've watched several others that range from creating CINs from scratch to a single provider group that reached out about telling me more about CINs. We took existing IPAs, such as that one they involved in the CINs and we took, and still manage, pins that subsequently launched CINs, and so they take different formats and we've been able to mail those over the years and so we have several now that we mail it, or IPA focused and some of our pHO focused. What we've seen is the core principles remain the same, right, and the reasons folks want to get in the CINs, the obstacles they've generally been the same, regardless of the market, regardless of the provider types or the provider settings. We've done them. Now We've got CINs in urban markets, we've got them in rural markets, we've got them in the south, we've got them in the Midwest. And when we reflect on those, it's kind of surprising how similar the conversations are within each of them. The same barriers, same mission, that sort of thing.

Jason: 18:14

And I'll say, while we were a little hesitant at first and we still sometimes are a little bit more restrictive on what to take on, we feel that our success as managers of IPAs right, and so that includes our services around provider enrollment, major care, contracting or analytics group, those types of things Naturally transition to managing CINs, not to mention just one of our goals as a company is to kind of stay tip of the sword from a market dynamics standpoint. Right, what's going on? How can we learn? And I think that's a good thing to say, the head of the curve, to be good consultants to our clients, and the CIN really allowed us to do that and, I think, makes us better consultants in general. So yeah, fast forward. Now here we are, eight years later. Again, we've got several CINs in different markets, and I think we're just better off for it.

Aaron: 19:12

You know SHPs have really been on the forefront and sounds like if CINs are still relatively in the last decade or so invention, SHPs really been there since it go, it sounds like we try to learn from our clients as much as they try to learn from us, and, I think, allows us to apply those principles regardless of the market.

Jason: 19:37

And it's also just an advantageous sort of venture by the providers themselves, which is exactly why we're in the game, right.

Aaron: 19:47

Right, and also, obviously, shp lowers the ramp or at least makes it easier for a provider or practice to form or join a CIN. But where does one begin? It is just, you know. Pick up the phone and call SHP or SHP aside, where does someone who wants to go into the alphabet soup? Where do they start?

Jason: 20:13

Yeah, great question. A couple of things. Number one appreciate patients, because the education and due diligence to simply think about and launching this initiative does will take several months at a minimum. So acknowledge the fact that this is not going to happen next month or the next quarter and most likely will be closer to the next year before it's up and going. So be patient, suck it, educate yourself. There's an abundance of material out there about CINs, both good, bad and the ugly right, and so, as I mentioned before, there's hundreds of CINs. Reach out to them. There's consultants like us on this webinar.

Jason: 20:54

So do your homework. First, the materials out there, free to be educated, and it'll help you craft your message as well to your peers in the community, which I would say is sort of the next step. So you do your homework. Once you feel prepared, engage with your peers, with other providers, other administrators in that market, right in your community. Discuss your concerns, your objectives behind a why you're thinking of the CIN. Essentially, you're going to talk through your why with your peers. That dialogue is going to help you fine tune the mission or the scope of sorts. It will also kind of simply start your due diligence process for you right. So having such a group from the start will provide insight and feedback to you, because you can't do it alone. Eventually, those same individuals will be your champions. They're going to be your board members, they're going to be your executive committee. They're going to help you launch the FT in the first place successfully.

Jason: 21:54

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 grasp of your objectives. Your partners. Legal counsel. Don't go out, try and get college-ranked still buying new platforms. Engage legal counsel. Yes, this will be unquestionably your largest expense for the first full year, but it's worth every penny.

Jason: 22:24

And, as I communicate to folks, there's two swim lanes with CIN success, legal and operational. Start with legal. So first of all, they'll help you refine those objectives. I mentioned the mission behind the venture. The discussion, also with your counsel, will transition naturally to what a successful operational gameplay and looks like. And also, once you have that legal conversation, you're going to get a better idea of the budget. Right, we see it so often that when push comes to shove, the budget is the biggest obstacle for the CIN to move forward successfully, and so once you have that conversation, you'll be able to better have those projections Early on. Establish it with that peer group I just mentioned, get comfortable with the legal framework you're having, the budget you're having, and now you can start taking all from. Okay, what do we need to do operationally to accomplish the mission we've been discussing thus far? And that's where your operational gameplay comes in. But those would be my first couple of steps. Educate yourself, engage your peers and talk to legal counsel from the get go. That's my first three tips.

Aaron: 23:38

Well, actually I think that leads to another question what was legal counsel? Obviously there's a lot of lawyers out there. I think the local Savannah market has one lawyer for every half person, it seems. So what sort of attorney would they be looking for? Business healthcare what typically have you seen been the most successful for CINs to use?

Jason: 24:07

Yep, those that have worked with other definitely healthcare, those oriented with healthcare networks, healthcare plans, any of those with we've worked, some that have recently left the FTC themselves, and so those that are used to M&A activity, collusionary type or collusion based sort of activity they're going to be most advantageous for you. They're going to be the ones that can best identify those red flags to be aware of and they are going to be focused on things like market share, providers, appropriate compliance right. When the provider's out of compliance, do you have a mechanism in place? They're going to be focused on that. So those that have that position based background around M&A, in particular the inclusion based activity, oftentimes it's going to be a larger group. It's going to be hard to find a law practice with two or three attorneys that have that sort of experience. So you might get one that's left the FTC recent. They're on their own, but oftentimes it is going to be the larger group. And, yes, they're going to be a large, hourly if you could as well, but definitely worth it, yeah, yeah no doubt.

Aaron: 25:23

Okay, I know we're running out of time here, so we'll get to the last couple of questions. So as the CINs continue richer again it's kind of that newer thing. Within the last decade or so it feels like that there's new goalposts that have been formed. So what can a new CIN expect to AC as those goalposts being today, and how can they measure their success against those key metrics?

Jason: 26:01

Yeah. So I try to emphasize a few pillars, if you will right. So be focused on appropriate and engaged governance structure, a data information plan, member engagement and engaged community partners and champions. And then, finally, a product deployment strategy, one that's flexible and not focused on one carrier or play in or mechanism. So as you talk through how to measure your success and metrics, it kind of falls under those key pillars that I've just mentioned and you want to separate those because you'll need different folks and champions within each of those, right? And so when I talk about product deployment, for example, be mindful of things like direct to employer agreements. Don't be so focused on just oh, I got to get my particular carrier playing up with things of that nature. Start looking at MA plans as well as commercial plans. Everything should be on your radar as far as a product deployment. But to get a little bit more granular, question a couple of those pillars I mentioned.

Jason: 27:11

Governance, for example. Right, your board is often the prize of physicians and administrators. Your executive committee is typically administrative driven, and then that next group of individuals you've got to launch is a QA committee. That is vital. That's going to come up in the first 15 minutes with your legal counsel. There are others you can launch as well, right, finance and contract and committee IT committee, et cetera. But start with those three. Your board you're exactly to me, your QA committee. We won't get into that, that's a whole other episode of it, and they love itself. Good data again. That looks them up as well in the first 15 minutes. With legal counsel, absolutely must have some form of information sharing as a CIN, preferably in a provider-led QA committee, right, and so just focus on that just for a second.

Jason: 28:01

Oftentimes you'll hear that a CIN is going to have a population health platform. Okay, first of all, be prepared for the sticker shock there. Platforms are very expensive, not just themselves, but every tax ID that has to get with their EMR vendor and they have to develop an interface. That's expensive. There's maintenance plans there, and so don't just stop there. There's other items to success from that legal checkbox that has to be met with data.

Jason: 28:34

Right, there's HIE options, health information exchange options. They're often less expensive. Folks are often already submitting data, most importantly the hospitals, and they're getting better from a reporting perspective. Another option in the favorite of mine is work with your TPAs, your employers. Oftentimes they've got tools in place and they've got specific programs they want to focus on and working with you. So therefore they can supply information to you. So you're not even have to worry about the costs or the resources it takes to store that information.

Jason: 29:11

So I'll give you a very specific example. We have a PHO that's CIN. They launched its QA committee solely with one large employer. A TPA supplies two or three PDF reports every month. The QA committee now knows they have to review those reports with that one employer around areas of integration. that helps your governance structure that I mentioned before, because that committee needs to be in place, comprised of employee docs, independent docs, different specialties, things of that nature, and you're able to document the minutes of that committee. So you see the sort of stair step benefits of working with the TPA for example, launching the QA committee, because you've got to document minutes for that committee. Your legal counsel is going to ask you that. And there's a ton more we can get into governance, like compliance plans, things of that nature, proper credentialing policies and procedures, communication, things like that. But yeah, the key success is being around proper governance structure than the information sharing that goes along with it.

Aaron: 30:22

To dovetail a little bit about PopHealth tools and those other analytical tools. You know, obviously we have QPP, we have a quality payment program and all the ways to participate in that. Do you see CINs as a way to participate in QPP using those sort of tools?

Jason: 30:44

Oh, absolutely. We've got a client that was an IPA that became a CIN and they became a CIN to that they get into an ACO and be a more successful ACO. So the CIN was sort of a prep work to be a successful ACO for engaging in that contract, and so I would take the same and apply it to QPP in that, in that that group can collectively work together, brainstorm together, and that's another benefit of the CIN is simply the networking with your peers of what tools do you use, what resources do you have. They can become their small group in terms of gathering the data necessary and submitting right, and I'll default to Aaron's QPP podcast on that, though I'm getting in the weeds there. But again, the collective nature of a CIN and the education and networking around it will also benefit you in your QPP venture. So, yes, I would definitely agree with that.

Aaron: 31:43

Okay. Well, thank you, jason, and now we're coming right up on time. So if folks want to learn more about CINs how to form one or how to participate in one how can they get in touch with you?

Jason: 31:57

Yeah, so feel free to give me an email jcrosby@shpllc. com. Let's schedule a call. We typically just talk through with you. I've got some key questions and various documents that serve as a template to help get your mind taken along those lines, and then you can go off and do your necessary to do the elegance. Yeah, let's set up a good 20 or 30 minute call. I think that'll be of great help to you.

Aaron: 32:24

That's great. Anything else you want to make sure our audience knows about before we head out?

Jason: 32:30

Look, guys, just don't get overwhelmed. It's just like when you guys had implemented EMRs and MIPS came out. There's an overwhelming feeling because of the amount of information out there. Simplified, it's not as complex as it's going to feel when you're reading, but just simplify it and be patient and give folks like myself a call. We'll help walk you through it.

Aaron: 32:50

All right, well, hey, thank you, jason, for your time today. Now you got a busy schedule, so thanks for clearing a few minutes for us to talk.

Jason: 32:58

Appreciate it, Aaron. Thank you and thanks for everybody for listening.

Aaron: 33:03

You've been listening to Beyond the Stethoscope Vital Conversations with SHP. This has been a production of Strategic Healthcare Partners, your news host today for Jason Crosby and me, Aaron Higgins. It is produced and edited by Nyla Wiebe. Our social media content producers are Nyla Wiebe and Jeremy Miller and our executive producers are Mike Scribner and John Crew. More information about SHP and the services we offer, including the back library of episodes, episode transcripts, links to resources discussed and much, much more, Please visit our website at shpllc. com. Thanks for listening.