Trends, Challenges and Opportunities in Behavioral Health Clinically Integrated Networks (CINs) 

Clay Farris, Kris Vilamaa, Steven Hedgepeth

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Intended readers: Community providers considering joining / forming a CIN, State HHS staff working with Community providers

Acronyms used in this article: Behavioral Health (BH),  Centers for Medicare and Medicaid Services (CMS), Certified Community Behavioral Health Centers (CCBHCs), Clinically Integrated Networks (CIN), Electronic Health Records (EHRs), Emergency Rooms (ERs) , Independent Provider Association (IPA) , Office of the National Coordinator (ONC), Substance Use Disorder (SUD), Value-based Care (VBC)

Need help forming or managing a CIN? Check out the info at the end of this article to learn more about what we can do to help. 

Introduction

Clinically Integrated Networks (CINs) represent a pivotal shift in the healthcare landscape, particularly in the behavioral health space. On the surface, CINs are collaborative arrangements among providers focused on improving quality and efficiency of care, while managing costs more effectively. CINs also play an important strategic role for both providers and plans: for providers CINs create a larger negotiating unit to broker better deals with plans on rates; for plans CINs create another layer of administrative cost that can be passed on to payers as part of the overall care coordination services plans provide. While much has been covered about other emerging BH payment vehicles like CCBHCs, BH CINs have not been widely covered outside their local contexts.

CIN formation is gaining momentum across various markets in the United States. However, the formation of CINs is not without challenges, ranging from the alignment of stakeholder goals to the integration of disparate data systems.

BH CINs offer much more potential to impact cost and care outcomes because the members they serve have some of the most severe needs. Members with BH needs are more likely to use ERs, have much higher health costs and are much more likely to be undiagnosed and untreated compared to members without BH needs. 

Reasons for CIN Formation

For providers considering forming a CIN, there are multiple benefits. It is important to consider the main reason(s) you might form a CIN. Here are the typical reasons providers form (or join a CIN): 

1. Increase Acumen to Address the Shift Towards Value-Based Care: The broader  transition to value-based care models is a significant driver for the formation of CINs. These models reward healthcare providers for the quality of care provided, rather than the volume of services delivered, thereby incentivizing collaboration and data sharing.
2. Improved Care Coordination: CINs play a crucial role in facilitating seamless transitions between different behavioral health providers and specialties. 
3. Increased Bargaining Power with Payers: By banding together, CIN members can negotiate better reimbursement rates and more favorable contracts with insurance companies. 
4. Enhanced Data Analytics and Quality Improvement: The collective pooling of data within a CIN allows for advanced analytics, which can be used to identify care trends, optimize treatment pathways, and enhance the quality of care.

Challenges and Solutions in Early Stages

CIN formation and operation also includes several challenges. Here are some of the typical challenges: 

1. Alignment of Goals and Priorities: The diverse nature of stakeholders within a CIN can lead to conflicts of interest and differing priorities. While member  organizations can gain initial alignment based on serving the same populations, providers (especially BH providers) often have very different cultures and operational models. Building a consensus and fostering trust early on are critical steps for overcoming these challenges. Strategies such as establishing clear communication channels and aligning incentives with the network’s overarching goals can facilitate this process.
2. Data Integration and Interoperability: The need to leverage more modern technology is often the key driver in CIN formation (and there are multiple vendors selling solutions, which also drives CIN interest). Merging data from various electronic health records (EHRs) poses significant challenges. HThe implementation and ongoing operation of these systems can be a major challenge for providers- but rich datasets are the most important asset in improved system performance and negotiation with payers (especially under VBC arrangements). 
3. Regulatory Compliance and Legal Considerations: Navigating the complex legal and regulatory landscape of payer-provider relationships is paramount for CINs. Providing resources and best practices, such as compliance toolkits and expert legal counsel, can help CINs address these concerns effectively. Unfortunately many CINs are converged predominantly to stand up a technology platform, and often shortchange the governance framework needed to operate a multi-member entity. 
4. Financial Sustainability: The initial costs of forming a CIN and ensuring its long-term viability can be considerable. CINs may need to secure external funding or develop innovative revenue streams, such as shared savings programs.

Examples of CINs

Technologies for CIN Success

Technology plays a key role in capturing all the data that CIN-participating providers need to coordinate services, monitor VBC performance and to get paid. Here are the main types of technology usually involved: 

1. Interoperable EHR Systems: The adoption of interoperable EHR platforms is essential for facilitating data sharing and information exchange across CIN-participating providers.  CMS has recently focused on interoperability and EHR systems for BH, and ONC is working on adding behavioral health integration measures in version 4 of its core datasets for interoperability. 
2. Telehealth and Remote Care Tools: Telehealth technologies have emerged as a vital component for delivering behavioral health services coming out of the COVID-19 pandemic. CINs utilizing telehealth effectively are able to reach specific populations or conditions, especially in underserved areas.
3. Data Analytics Platforms: The use of sophisticated data analytics tools is critical for performance measurement, quality improvement, and population health management within CINs. These platforms enable CINs to leverage their collective data for insightful analysis, decision-making and VBC payment arrangements.

Conclusion

CINs are currently limited, but at the forefront of transforming healthcare delivery. Behavioral health CINs present the most significant opportunity for impacting quality and costs because of the higher needs of the members they serve and the overall system maturity level of most BH networks.

Through improved care coordination, enhanced bargaining power, and advanced technologies, CINs can quickly make progress. However, addressing the challenges of goal alignment, data integration, regulatory compliance, and financial sustainability is crucial for CINs. As payment pressures on providers increase, the need to form successful CINs will also increase. Payers should look to support smaller providers’ participation in well-organized and governed CINs as part of their effort to improve patient access and control costs. 

Need help planning, forming or operating a CIN focused on BH providers and members? 

Our team has decades of experience helping to transform the behavioral health system. We focus on assisting HHS agencies (state and local) craft and evaluate policies, and we help community providers implement system change directly. To learn more about what we can do to help you implement or improve a BH CIN, send a note to steven.hedgepeth@mostlymedicaid.com. 

Further Reading 

1. Setting the Foundation for a 7 Steps Playbook Clinically Integrated Network, Conifer Health Solutions. https://www.coniferhealth.com/wp-content/uploads/Conifer-Health-7-Steps-CIN-eBook.pdf
2. ‘The time is now for clinically integrated networks’, Lia Novotny. https://www.athenahealth.com/knowledge-hub/practice-management/time-now-clinically-integrated-networks
3. A Path to Clinical Quality Integration Through a Clinically Integrated Network: The Experience of an Academic Health System and Its Community Affiliates, Lawrence S. Friedman, MD, et al.  The Joint Commission Journal on Quality and Patient Safety. https://www.jointcommissionjournal.com/article/S1553-7250(20)30240-3/fulltext
4. Increasing Access to Behavioral Health Services: Opportunities at the State and Federal Level. Miriam Pearsall, Sandra Wilkniss. https://nashp.org/increasing-access-to-behavioral-health-services-opportunities-at-the-state-and-federal-level/
5. Arizona Behavioral Health Providers Form Clinically Integrated Network. David Raths.  https://www.hcinnovationgroup.com/population-health-management/behavioral-health/news/21284730/arizona-behavioral-health-providers-form-clinically-integrated-network
6. Integral Health Network of Southern Arizona to assume clinical and fiscal responsibility to assume clinical and fiscal responsibility for Banner – University Health Plans Members diagnosed with co-morbid medical and behavioral health conditions. https://www.bannerhealth.com/newsroom/press-releases/integral-health-network-of-southern-arizona-to-assume-clinical-and-fiscal-responsibility
7. Success in our state. https://clinisync.org/wp-content/uploads/2022/03/ISBH-Success-Story.pdf
8. About Convergence Integrated Care. https://www.macmhp.org/about-cic
9. CIN Case Study: Coordinated Behavioral Care IPA. How an innovative independent practice association streamlined social service referrals. https://www.chcf.org/cin-case-study-coordinated-behavioral-care-independent-practice-association/
10. CLINICALLY INTEGRATED NETWORKS: BUSINESS AND LEGAL CONSIDERATIONS. Claire Turcotte. https://ohiohospitals.org/getattachment/Member-Services/Personal-Membership-Groups/OSHRM/Turcotte-Yanci-Presentation.pdf.aspx
11. HHS Roadmap for Behavioral Health Integration. https://www.hhs.gov/about/news/2022/12/02/hhs-roadmap-for-behavioral-health-integration-fact-sheet.html
12. Rural hospitals form clinically integrated network in North Dakota. ALEX KACIK. https://www.modernhealthcare.com/providers/north-dakota-critical-access-hospitals-network
13. Reimagining rural health care with integrated networks. DANNY SCHMIDT. https://realeconomy.rsmus.com/reimagining-rural-health-care-with-integrated-networks/
14. Key Considerations in Forming, Operating or Joining a Clinically Integrated Network (CIN) . American Medical Association. https://www.ama-assn.org/system/files/private-practice-checklist-cin-considerations.pdf
15. Why Join a Clinically Integrated Network? North State Quality Care Network. https://nsqcn.org/network/why-join-a-clinically-integrated-network/
16. About My Texas Health. https://texascin.com/#86b7060c-3683-4bef-b733-824d0c9fa65b