Whether reading the national business and health care journals, scoping the Facebook posts from patients and health execs, or watching the nearby hospitals and health care providers here in Florida, the simple answer to this question ranges from "Gee, that's an interesting merger" to "Nothing integrated when the numbers of poor health keep rising." In short, integrated networks are still not operating past the beginner levels, with a few exceptions.

As a quick refresher, the concept of integrated networks emerged mid-1980s to offset the exploding costs of delivering care. These early trials were built on cost cutting and efficiencies of scale in purchasing, not on patient or community outcomes. Merger begat merger, through managed care, health system purchases, and physician acquisition. Each tailored "network" promised lower prices and better outcomes, but big promises became small deliveries.

Fast-forward 20 years and the new networks are growing larger, particularly in the physician-owned and/or driven acquisitions, with the hopeful goal of reorganizing payment based on outcomes. While some pockets of ACO-PPO-HMO-HDHP overlap are testing the payment models, we have still not seen sustainable, replicable, and predictable outcomes, even in more forward networks such as those in the Northeast and West coasts.

The current state is flummoxed because of the lack of interoperability and delivery of full data to patients, complicated by the jet-propelled rise of drug costs and treatments. There are three opportunities for true integration that can include the patients in the patterns of care while managing the appropriate treatments and delivery of efficiencies.

1. Government. In order to achieve patient compliance and patient-provider trust for getting to goal, treatments and services must be transparently priced. The major stumbling block is the government's inability to negotiate Medicare drug prices, aggravated by separate system of validation and pricing of devices. When complicated cases are present, the patient expects to be treated by the best treatment and physician recommendations. Trust is broken when clinicians do not know pricing or are paid bonuses for using brand/generic/device that the payer prefers, regardless of patient impact. When the patient-provider trust is impugned, goals are not achieved, more services are required, and costs go up. Medicare drug management is the key to making rapid strides in trust, compliance, outcomes, and value.

2. Government. (No, this is not a typo) The government-as-employer should, by dollar definition, be able to set the leadership for other employers and payers in an area. Yet, the integration of the DOD and VA health records is still a shambles, despite the US being the richest container of tech savvy. The remarkable revelations of inappropriate data outcomes from the CDC, FDA, and other "health" agencies demonstrates the confusion in the system that first proposes "Big Data" as the cure to integration and interoperability, and then stumbles on the timeliness and consistency of the measures. The integration of health networks will accelerate and progress when the standards for measures AND communication to the various stakeholders is functioning appropriately, demonstrating the relationships of costs, communication, and compliance for various populations in the US and beyond.

3. Government. The insanity of providing geographically-bound medical plans is an overwhelming problem in the US. A good example is a Kansas City patient, obviously on the Missouri-Kansas border, using clinicians for treatment on both sides of the border and having to manage the requirements not only of her health plan but also the out-of-network care, eligibility to receive care, and so forth. Deductibles, copays, out-of-pocket expense, physician/system choice are all compromised. Imagine what happens when people travel to out-of-state care for cancer. Imagine what happens when one network has to intersect with another- integration of any kind, even sharing patient-level data, is more often missing-in-action.

The bully pulpit of the US health experts, US tech experts, and US patients must be the placed as the core of data-design-delivery in order for integration in health care to occur. Anything less will continue to be networks-for-optimum-billing, which is not at all focused on patient or system outcomes, nor on building a healthier US.

CINs - "The State of the Union":  In most markets, CINs are today more aspirational than anyone likes. By "anyone" I mean the policy makers who would like them deployed to help realize value based purchasing goals, hospitals that would like them ready as vehicles to develop and enforce care paths, independent physicians who would like them to be shelter from the pressures to accept hospital system or other employment, employers who would like local experienced value based contracting vehicles -- to name a few.

Most CINs are probably stalled over insufficient bonus money at the ready (or plausible) to get their participants' attention/change practice patterns. Payors are not waking up every morning wanting to contract with a CIN. Face it, its work. There are special contracts to write, there are reports to be created and run, reconciliations to be negotiate, compliance can be more difficult, and the likelihood of medical management success is uncertain. Can they reasonably be expected to prioritize this spend within a 15% of the premium that already seems stretched by expenses?

Is "help on the way"? The optimists should point to the opportunity of the "alternative payment methodology" under MACRA as a driver. They might also cite other pressures to create the infrastructure-needs for structures to handle current and future episode payment needs and platforms to fight inappropriate readmissions among others.

The pessimists would argue that even the above do not aggregate to a "tipping point". They would argue that until new incentives are created among the buyers (e.g., mandates to commercial, MA and Medicaid plans) plans will not invest enough into building CIN relationships for them to take off. Similarly, self-funded plans lack the incentives to spend their assets to build the chassis for local population health management.

However, this is an election year...ideas will be hatched and will gain currency. Some of those incentives to stimulate the payor market to seek out and facilitate CIN development are within the legislature's reach. Ah...to dream.
 

California arguably has the most robust clinical integration activity in the nation with at least 67 ACOs serving about 1.3 million people. According to the Berkeley Healthcare Forum at the University of California - Berkeley School of Public Health, the state is well on its way of achieving the goal of 60% of the population under integrated care by 2022. Medical groups under ACO contracts are beginning to show higher quality metrics in several areas of condition management (cancer, diabetes, pediatric care and Chlamydia) as well as patient service categories versus groups that are not participating in ACO models. (Shortell and Scheffler, Health Affairs Blog, 6/2/2015) These programs are delivering results and, if these trends continue, clinically integrated care will be the most significant factor in improving population health and decreasing medical costs.
 
Success will depend largely on making progress on both the technological aspects of integrated care along with the human/cultural dimensions. Strides in the interoperability of Health Care IT, Electronic Health Records and patient portals must be coupled with the ability of provider staff, patients and families to effectively interact with the technology. The value of systems will only be as great as the willingness of people to use them to enhance the flow of current, relevant patient information when and where it is needed.
 
This is especially true for the consumer engagement of patients and their families as fully participating partners in the delivery of health care. Movement must continue in the direction of making the patient interface not just easier to access, but actually engaging and useful to them. Widespread availability of smart phones and tablets is an opportunity we can seize to help close this part of the loop. The patient engagement must not only prompt communication about illness and injury but emphasize wellness and fitness also. In addition to the basic functionality of patient-system interaction, consideration for language and cultural preferences among different segments of the population is essential.

The goal of clinical integration has often been stated: "to maximize the value of services delivered." Measurement of this goal must recognize both the technological and human challenges of achieving it. Inherent in the word "value" is also an understanding of the cost-benefit relationship. Reaching the goal of clinical integration will require continuous measurable improvement along all of these dimensions.
 

The question around the state and impact of CINs is one of HUGE importance. That said, my short answer is "We really don't know." The CIN movement has been stealthier than the development of B1 bombers.

The promulgation of CINs was initiated and promoted by the Federal Trade Commission guidance in the mid-1990s. The CIN construct was the government's response to the industry's spawning of "financially" Integrated Delivery Systems in the early 1990s. The intent was to provide antitrust guidance by allowing clinically beneficial integration initiatives across provider organizations while discouraging veiled anti-competitive practices.

As of 2008 there were only a handful of CIN initiatives in the US; by 2013 the Advisory Board reported that there were some 500 CINs in existence. Who/what are they? Don't know -- I've never actually seen a list of CIN initiatives.

Contrast the dearth of information about CINs with the plethora of information and discussions around ACOs. ACOs have been widely reported on in excruciating detail. I'd imagine there's a fair amount of overlap between a list of ACOs and a list of CINs -- but that's conjecture. A few CINs have been above the radar -- Advocate in Chicago is the poster child example of a visible, successful, aggressive CIN.

The structure of CINs has been highly regulated. Ideally, CINs would be driven primarily by clinicians seeking to promote integrated patient care and secondarily by business executives focused on creating effective partnerships and alliances. Yet, the creation and guidance of CINs has been driven and controlled by lawyers and compliance officers.