Drive to improve quality, reduce costs unites practices in clinically integrated networks
AlysonSulaski Wyckoff, Associate Editor
Some pediatricians around the country are boosting quality, cutting operating costs
and pocketing bonuses for their practices in exchange for data-sharing and other requirements.
They are part of clinically integrated networks (CINs), where medical practices join
forces, often with hospitals, to improve quality and efficiency.
“Coming together in these groups allows us to more forcefully advocate for improved
payment to help support the quality efforts that we’re working on, because these things
do take time and money and we need the support to do that,” said Christoph R. Diasio,
M.D., FAAP, chair of the AAP Section on Administration and Practice Management Executive
Committee. His North Carolina practice, Sandhills Pediatrics Inc., is part of a large
While CINs vary in structure, members pay dues and commit to follow clinical protocols,
track performance and share data. They set goals such as increasing immunization rates
or lowering emergency visits. If members collectively demonstrate better outcomes
and efficiencies, the network can improve its negotiating power with payers. The CIN
also might reward them with bonuses and other perks.
Hospitals are at the core of many CINs because “sometimes you need a hospital-sized
organization to have the money to get it started and build out the infrastructure,”
Dr. Diasio said. The networks are strong in some parts of the country, nonexistent
Collaborative but still independent
Children’s Hospital Colorado introduced providers in the Denver area to the potential
benefits of CINs.
“It took a long time and many meetings for us to get to the point of feeling very
comfortable with moving forward with creating a CIN,” said Noah J. Makovsky, M.D.,
FAAP, founder of Stapleton Pediatrics in Denver.
Meetings were held for more than a year before most practices agreed to join. Determined
to retain their independence, the practices agreed that primary care doctors would
hold most of the governing seats, said Dr. Makovsky, who chairs the board of managers
of the CIN, Pediatric Care Network. The CIN now includes 200 primary care and 800
specialty physicians and, in Dr. Makovsky’s view, the arrangement is thriving.
“The trust level between pediatric practices, as well as between practices and Children’s
Hospital, is really heading in the right direction,” he said. “We feel like we can
truly collaborate. We can have honest conversations about the future of medicine,
and that is a huge advantage.”
Norman “Chip” Harbaugh Jr., M.D., FAAP, understands the need for physician independence.
More than 20 years ago, the managing partner of Children’s Medical Group in Atlanta
became frustrated with what he saw as insurance companies taking advantage of physicians
at two local children’s hospitals (now merged as Children’s Healthcare of Atlanta).
The hospitals were bickering, and the physicians were at odds, he recalled.
“It just didn’t seem right, so I decided I would like to see physicians or pediatricians
have more control over the quality as well as the future of medicine,” Dr. Harbaugh
said. He convinced the physicians to join an independent pediatric primary care physician’s
association. The pediatric subspecialists later formed their own group, and eventually
the two entities joined with Children’s Healthcare of Atlanta and established the
CIN, Children’s Care Network.
“All of us together have quality metrics … so it’s a unified pediatric delivery model
—hospitals, specialists and primary care,” Dr. Harbaugh said, adding that they are
“proving to insurance companies, both public and private, that we really can move
the needle on quality.”
Denver CIN members are working hard to define pediatric value-based care, at least
locally, Dr. Makovsky said.
“We’re not as interested in somebody imposing what those quality standards are that
we must follow, but rather trying to collaborate with the payers,” Dr. Makovsky said.
The CIN explains to payers what it believes will improve the health of patients while
decreasing utilization and costs.
When evaluating whether to join a CIN, pediatricians must ensure they have a voice
at the table, said Carolyn T. Cleary, M.D., FAAP. The Rochester, N.Y.-based pediatrician
at Elmwood Pediatric Group is on the board of managers of Accountable Health Partners
(AHP), a CIN with 2,000 providers and eight hospitals.
“The big question pediatricians always have is what are going to be the quality metrics
that we’re graded on,” said Dr. Cleary. She suggests making sure the CIN has pediatric
representation and that the quality metrics are relevant. While some pediatricians
might be concerned about too many rules, she has not found that to be the case with
“The quality metrics that we’re being asked to follow are standard metrics that follow
all of the AAP guidelines. None of the requirements were unreasonable,” she said.
Sharing data, solutions
CIN members can benefit by comparing data to see how their practices are performing.
They also have the opportunity to network on solutions to common problems. “There
are a lot of things that are clinical problems no one really thinks about until they’re
trying to improve quality,” noted Dr. Diasio.
In Denver, improving asthma outcomes is a goal of the CIN. Recently, a hospital pulmonologist
visited primary care offices to discuss best treatments. Dr. Makovsky called this
a good example of members working together to benefit children, which also reduces
“Hopefully, we as pediatricians are touching thousands or maybe hundreds of thousands
of lives, and we can really make an impact … if we are decreasing utilization and
decreasing costs of health care to take care of these kids,” Dr. Makovsky said. “I
think that’s a wonderful form of collaboration that we’ve seen within this CIN.”
Pediatricians considering forming or joining a CIN should start by having heartfelt
conversations about what it means to practice pediatrics in their community, Dr. Makovsky
“It seems so basic,” he said, “but those face-to-face conversations on a regular basis
are what I believe really forms the foundation of being able to build a successful