Revisit: Keys to a Successful CIN | With Jason Crosby

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

Aaron: 0:39

Welcome to Beyond the Stethoscope Vital Conversations with SHP. As we take our summer break to prepare for the exciting Season 5, we're revisiting some of our most insightful episodes to keep the conversation going. In this episode, originally aired all the way back in Season 1, we explore the fascinating journey of building a healthcare network from the ground up. Jason Crosby, our resident healthcare expert with over 25 years of experience, joins us to dive deep into the world of clinically integrated networks, or CINs. From the challenges of value-based care to the legal intricacies of forming a CIN, jason shares his extensive knowledge and experience. So, whether you're a healthcare professional or simply curious about the inner workings of this vital industry, this episode offered a unique glimpse into the evolution of healthcare networks. Don't miss this opportunity to revisit an essential conversation that remains relevant today and, as always, if you find this episode helpful, please rate and share our podcast in your favorite podcast app. It really helps us reach more listeners. Let's join Jason Crosby and myself as he takes us behind the scenes of CINs.

Jason: 1:51

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

Aaron: 1:54

Yeah, alrighty. 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. You know what, what is your background, you know what, what makes you a vital conversation.

Jason: 2:27

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 it's my first air quotes. Real job was an entry-level descent support analyst at a different health system, Was there for several years in descent support and IT, did the project management thing, did the Six Sigma and ended up manager of decision support, which was my first management gig and probably still to this day one of my favorite jobs. I really enjoyed that Left there, became finance director for a large ER physician group and then came to SHP about 13 years ago and so, honestly, the which, looking back the health system and the practice settings, really, I 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: 3:43

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

Jason: 4:13

Yes, let's. Let's get ready for a three-letter alphabet soup here. Um, cin, a clinically integrated network. So go back about 25 years, 30 years or so, the FTC came in and 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 CI 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: 5:01

But in essence, a CIN is simply as a clinically ingrained network, even though it's got many definitions, it's its own legal entity. It's comprised of multiple organizations, including providers, physicians, health system, age layer groups, et cetera. That basically it's intended to achieve what we now know and call the AAA and principle of healthcare, right? So these entities, they take on various forms, various modes of evolution, the most typical being your PHO, just adding another three-letter acronym out there Physician Hospital Organization, type of entity where you have a hospital alongside their employed physicians, sometimes the community independent providers.

Jason: 5:49

The other common form we see is a collection of independent docs or an IPA. You know each of which we've worked with in the past and we do today. So we're an IPA, you know 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 C-Ions are out there, but a few years ago Becker's released a study of theirs. They estimated over 500, and this was 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 C-Ions out there and really what they're about no-transcript.

Aaron: 6:28

You brought up another little alphabet soup 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 overlay?

Jason: 6:47

Imagine a stair step of collaboration and legal framework. IPA is going to be your first step. CIN is your natural evolution to a second step. Then you have ACOs et cetera, 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 the 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, IPA's are typically more managed care, contract, fee for schedule sort of focus. CIN is going to be a little bit more value-based care oriented, you know, working with employers, things of that nature. So there's a definite legal structure that differentiates the two, structure that differentiates the two.

Aaron: 7:51

So you know obviously we're SHP. One of the services that we offer is SCI and management and development. How did SHP start playing in that space?

Jason: 8:05

Yeah, so around 2013-ish 2014, we had an IPA client of ours. It had roughly 25 independent specialty-based groups, right, and they're in a market that did not have a value-based care present. So one of the physicians, literally, were sitting in a board meeting and they brought it up like guys, how can we collectively move towards value-based care as a group? Number one? Number two 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 integrated 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 the SHB split up the duties, went off for about nine or 10 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 it allowed them to have a different entity in which it could serve the purpose of a CIN, right? But the IPA was a matured organization, matured contract portfolio, and so they felt the CIN 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 was general research on just CINs, a provider engagement, a recruitment into the CIN. And so you go back 2013, 2014,. For those listening and started 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, um. So since then, after that CI and we, we've launched several others, um that range from creating CINs from scratch to a single provider group that reached out about.

Jason: 10:49

We took existing IPAs, such as that one, evolved them to CINs, and we took and PHOs that subsequently launched CINs and so they take different formats and we've been able to manage those over the years, and so we have several now that we manage that are IPA focused and some are PHO focused. What we've seen is the core principles remain the same, right, and the reasons folks want to get into 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 South, we've got them in the Midwest.

Jason: 11:35

And when we reflect on those, it's kind of surprising how similar the conversations are within each of those same barriers, same mission, that sort of thing. And so, 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, managed 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 dynamic standpoint, right, what's going on, how can we learn, how can we stay ahead 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: 12:45

You know SHP has really been on on the forefront.

Jason: 12:47

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 to learn from our clients as much as they try to learn from us, and I think it allows us to apply those principles regardless of the market, 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: 13:19

Right. 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? Is it 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: 13:45

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 about and launching this initially 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. Second, educate yourself.

Jason: 14:14

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 CIN's. Reach out to them. There's consultants like us on this webinar. So so do your homework. First, the materials out there um free to be educated, um, 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.

Jason: 14:43

Once you feel prepared, engage with your peers, with other providers, other administrators in that market in your community. Discuss your concerns, your objectives behind it, why you're thinking of a 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 entity in the first place successfully.

Jason: 15:27

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 Find legal counsel. Don't go out trying to get contracts. Don't buy any platforms. Engage legal counsel. Yes, this will be unquestionably your largest expense for the first full year, but it's worth every penny.

Jason: 15:57

And, as I communicate to folks, there's two swim lanes with CI and success legal and operational. Start with legal. Okay, 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 game plan 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 CI and the move forward successfully, and so once you have that conversation, you'll be able to better have those projections early on establishing with that peer group I just mentioned.

Jason: 16:43

Get comfortable with the legal framework you're having, the budget you're having, and now you can start taking off 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. 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: 17:10

Well, actually I think that leads to another question what sort of 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: 17:40

Yeah, those that have worked with other healthcare networks, healthcare plans, any of those with we've worked, some that have recently left the FTC themselves. Um 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 a 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, 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 and 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 uh refugiate as well, but definitely worth it.

Aaron: 18:54

Yeah, yeah, no doubt. Okay, I know we're we're running out of time here, so, uh, time here, so we'll get to the last couple of questions. So, as the CINs continue to mature 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 you know, what can a new CIN expect to see as those goalposts being today, and how can they measure their success against those key metrics?

Jason: 19:32

Yeah, 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 strategy, one that's flexible and not focused on one carrier or plan or mechanism. And 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, and when I talk about product deployment, for example, be mindful of operate, though, because you'll need different folks and champions within each of those right and so, and 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 plan up, or 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: 20:43

Governance, for example. Right, your board is often comprised of physicians and administrators. Your executive committee is typically administrator 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 contracting committee, it committee, et cetera. But start with those three your board, your executive committee, your QA committee. We won't get into that, that's a whole other episode of it in and of itself. And then data Again, that will come up as well in the first 15 minutes of legal counsel. You 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: 21:33

Oftentimes you'll hear that a CIN is going to have a popular platform. Okay, first of all, be prepared for the sticker shot there. Now just, are you required to have a platform? No, okay, we'll get onto that in a second. But pop health 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.

Jason: 22:01

There's other paths to success from that legal checkbox that has to be met with data, 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 carriers, your employers. Oftentimes they've got tools in place and they've got specific programs they want to focus on and work 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: 22:43

I'll give you a very specific example.

Jason: 22:45

We have a PHO that's a CI and they launched its QA committee solely with one large employer.

Jason: 22:52

A TPA supplies two or three PDF reports every month. That QA committee now knows they have to review those reports for that one employer in the discussions around areas of impregnation. Okay, and that helps your governance structure that I mentioned before, because that committee needs to be in place and comprised of employee docs, independent docs, different specialties place, and 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 you know stair-step benefits of working with the TPA, for example, and 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 with governance, like compliance plans, things of that committee your legal counsel is going to ask you that and there's a ton more we can get into with governance, like compliance plans, things of that nature, but proper credentialing policies and procedures, communication, things like that. But yeah, the key success is being around proper governance structure, then the information sharing that goes along with it.

Aaron: 23:55

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 to participate in that. Do you see CINs as a way to participate in QPP using those sort of tools in QPP?

Jason: 24:16

using those sort of tools. Oh, absolutely, I think, whether it's QPP. We've got a client that was an IPA that became a CIN and they became a CIN so that they can 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, 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. 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, okay.

Aaron: 25:16

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

Jason: 25:30

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 just to help get your mind thinking along those lines and then you can go off and do your necessary due diligence. Yeah, let's set up a good 20 or 30-minute call and I think that'll be of great help to you. That's great. Anything else you want to make sure our audience knows about before we head out? No, 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. Simplify it. 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: 26:24

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: 26:31

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

Aaron: 26:35

You've been listening to Beyond the Stethoscope vital conversations with shp. This has been a production of strategic health care partners, your news host today, for jason crosby and me, aaron higgins. It is produced and edited by nyla weave, our social media content producers are nyla and jeremy miller and our executive producers are mike scrivener and john crew. More information. Thanks for listening.