Clinically integrated networks play key role in health care

Ashley Thurow

I’m often asked what we do at Monument Health.  As a clinically integrated network, or CIN, our involvement with health care providers and insurance companies can be complex and difficult to explain.  

Clinically integrated networks work with insurance companies, doctors and patients to align incentives among the three parties and better coordinate health care. CINs can be a powerful catalyst for achieving what’s called the triple aim of health care — improving the health of populations and experience of care while reducing per capita costs.

Improved quality and lower costs have proven mutually achievable goals using the CIN care model. We’re able to do this because we hold physicians accountable to standards for access, targeted quality improvement and cost reduction. We focus on preventive care and helping patients live healthy lives. And we monetarily reward doctors when they achieve better health outcomes. In other words, we have financial responsibility to ensure our providers and hospital partners deliver better care according to network standards.

Compared to the rest of the United States, Colorado is behind the curve in using CINs to achieve the triple aim. States like Utah and California have had CIN-like organizations engaged in this work for decades.  The ultimate goal, which can be seen in those states, is downside risk — doctors take on full medical and financial responsibility for their patients. Kaiser Permanente, Geisinger Health System and Intermountain Healthcare are all well-known examples of organizations that operate this way. These organizations align providers and health insurance to reward responsive care and cost containment. We refer to this full risk, all-inclusive scenario as capitation.  

In a capitated model, doctors are paid one fixed amount to care for an entire population of people. Physicians then have the freedom to engage with patients much like the house call doctor of the early 1900s — developing close relationships focused on staying healthy. Not only is this model more rewarding for doctors and patients, it also saves consumers a lot of money.

For a health care entity like a hospital or primary care clinic, jumping into a capitated model is a complicated endeavor that requires a considerable amount of infrastructure, particularly data infrastructure. Most CINs begin by taking on partial risk while they build out infrastructure. An example of partial risk is the arrangement Monument Health has with Rocky Mountain Health Plans to support its Medicare advantage plan. Our providers aren’t paid an all-inclusive, fixed amount.  However, we partner to manage costs and patient care. If we’re successful and the plan is rated high quality with reasonable spending, we all share in the financial benefits. 

More examples abound at Monument Health, where we specialize in supporting hospitals and primary care providers with data to better coordinate patient care. We’ve built a data infrastructure that enables us to look at medical claims and electronic health records (EHRs) to understand areas where patients seek too much care or not enough. We use this data to encourage patients to see their primary care doctors for annual exams, preventive blood work, cancer screenings and more. We work closely with doctors to better coordinate care — patients are fully supported when they leave the hospital after experiencing an emergency, for example.

Our goal is to keep patients healthy so they’re less likely to visit an emergency room — the most expensive place to go for care—to address their health care needs. The result is a healthier community, which benefits us all. 

Statewide, there are thousands of doctors starting to take on financial risk for their patients, coordinated with the help of CINs. On the Front Range, Centura’s Colorado Health Neighborhoods, UC Health’s Coordinated Care Colorado and Children Hospital’s Pediatric Care Network constitute examples of similar entities engaged in this work.  

Monument Health is the largest CIN on the Western Slope and among the largest in the state. We serve more than 20,000 patients, a number I expect to quadruple in coming years as the federal government and private insurance companies push for doctors to move into downside financial risk.  

Ultimately, doctors participating in CINs to take on financial risk is good news for patients because it fosters strong provider relationships and focuses on prevention.

As this movement progresses, patients should expect to become more engaged in a primary care setting and have less need to self-navigate their own health care. Ideally, the patient-primary care doctor relationship will be front and center for all Coloradans. The primary care doctor will be the go-to resource for those with questions or concerns relating to their health.  

While the concept of preventive care with a trusted physician seems simple, it’s fundamentally absent from the lives of many Coloradans. But with the support and growth of CINs like Monument Health, the paradigm is changing.  

Ultimately, prevention is the key to slowing the relentless growth of health care costs. CINs can serve as the catalyst for prevention-focused change in health care.