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PubMed2002

Independent practice associations in New Zealand: a study of governance structures and process.

AIMS: To describe the governance structures and processes of four primary care organisations (PCOs) and to evaluate member general practitioners' (GPs) perceptions of the effectiveness of these structures and processes. METHODS: A sample of four PCOs was chosen in 1999, including three independent practitioner associations (IPAs), and a member organisation of CareNet. The chief executive officer of each PCO was interviewed, and the 245 member practitioners were surveyed with a written questionnaire. RESULTS: The response rate to the GP survey was 78.4%. A two tier governance structure was identifiable for all four PCOs: policy board or steering committee, and working committees. In addition each utilised a peer group review process to provide input to some administrative functions. The CareNet PCO emphasised reduced bureaucracy and a loose administrative structure and process. There was a high level of respondent satisfaction (>90%) with their PCO governance processes. CONCLUSIONS: Governance structures and processes have developed within the four PCOs that reflect the needs of member practitioners and according to the requirements of each district and PCO membership. A high level of member satisfaction with their PCO, its governance and processes, was evident.

Attitude of Health Personnel↗
PubMedDate not supplied

Independent practice associations: risk contracting, financial controls and processes.

The decision to enter into risk contracting with a health plan should be carefully considered. With today's pressure to control health care costs, an IPA's financial position can change rapidly. Even small numbers of enrollees can precipitate losses of hundreds of thousands of dollars over a few months if utilization and costs are not carefully projected and monitored. Prudent contracting to limit the IPA's downside risk in a new contract's early years is the most effective tool for preserving financial stability. However, the IPA must also develop sophisticated claims processing and financial reporting systems to ensure consistent payment practices and enable management to identify problem areas rapidly. Contracts with physician providers must allow the IPA flexibility in implementing administrative withholds and in renegotiating rates with short lead times.

Capitation Fee↗
PubMed2006

Medicare HMO penetration and mortality outcomes of ischemic stroke.

OBJECTIVE: To examine associations between Medicare health maintenance organization (HMO) penetration and stroke mortality outcomes among older persons. STUDY DESIGN: Panel analysis of nationally representative secondary data from 1993 to 1998. METHODS: The first analysis sample included ischemic stroke hospitalizations among older persons in the Nationwide Inpatient Sample; the second included county-level ischemic stroke deaths in the National Vital Statistics System. The 2 samples were merged with the HMO enrollment data and the 2001 Area Resource File. The 2 outcomes were in hospital death status and county-level population ischemic stroke death rates among older persons; the 2 utilization variables were length of hospital stay for ischemic stroke and proportion of ischemic stroke deaths occurring in hospitals. The 3 key explanatory variables were county-level Medicare total, independent practice association, and nonindependent practice association HMO penetration. Ordinary least squares analysis with hospital or county fixed effects was used in estimation. RESULTS: Medicare HMO penetration was not associated with the 2 ischemic stroke mortality outcomes (P > .05). Increases in Medicare total and independent practice association HMO penetration were associated with a significant shift in a higher proportion of stroke deaths from hospitals to nursing homes or residences (P < .05). Medicare HMO penetration was negatively associated with length of stay, although this was not statistically significant (P > .05). CONCLUSIONS: Increased Medicare HMO penetration was associated with a shift in ischemic stroke deaths from hospitals to nonhospital settings. The effect of Medicare HMO penetration on quality of stroke care needs further research.

Aged↗
PubMed1987

Use of ambulatory health care services in a preferred provider organization.

The organization of the delivery of health care can have significant cost-saving implications, but few of the available studies have made adequate comparisons of costs across plans. Furthermore, new organizational types such as independent practice associations and preferred provider organizations have not yet been studied in detail. This paper examines ambulatory utilization in a preferred provider organization (PPO) for Uniformed Services beneficiaries at Pacific Medical Center (PMC) in Seattle. The utilization in the PPO is compared with the results of a recently reported study of three other organizationally different Seattle plans: a Blue Cross/Blue Shield plan (BC), a closed-panel health maintenance organization (HMO), and an independent practice association (IPA). The PPO was similar to the IPA and the HMO in having a high percent of patients with any ambulatory use and had standardized ambulatory costs per user which were lower than BC but higher than the HMO. Thus, this particular type of PPO may have cost-saving features, particularly because the Uniformed Services population is known to use more health services than the general population. Methodological issues for future utilization research across organizations are also discussed.

Adolescent↗
PubMed1999

Integrating clinical performance improvement across physician organizations: the PhyCor experience.

BACKGROUND: There is a paucity of literature describing the implementation of clinical performance improvement (CPI) efforts across geographically dispersed multispecialty group practices and independent practice associations. PhyCor, a physician management company based in Nashville, Tennessee, has integrated CPI initiatives into its operating infrastructure. PhyCor CPI INITIATIVES: The strategic framework guiding PhyCor's CPI initiatives is built around a physician-driven, patient-centered model. Physician/administrator leadership teams develop and implement a clinical and financial strategic plan for performance improvement; adopt local clinical and operational performance indicators; and agree on and gain consensus with local physician champions to engage in CPI initiatives. The area/regional leadership councils integrate and coordinate regional medical management and CPI initiatives among local groups and independent practice associations. In addition to these councils and a national leadership council, condition-specific care management councils have also been established. These councils develop condition-specific protocols and outcome measures and lead the implementation of CPI initiatives at their own clinics. RESOURCES: Key resources supporting CPI initiatives include information/knowledge management, education and training, and patient education and consumer decision support. PRELIMINARY RESULTS AND OBSERVATIONS: Localized efforts in both the asthma care and diabetes management initiatives have led to some preliminary improvements in quality of care indicators. CRITICAL SUCCESS FACTORS AND CHALLENGES: Physician leadership and strategic vision, CPI-oriented organizational infrastructure, broad-based physician involvement in CPI, providing access to performance data, parallel incentives, and creating a sense of urgency for accelerated change are all critical success factors to the implementation of CPI strategies at the local, regional, and national levels.

Group Practice↗
PubMed1997

The impact of physician economic incentives on admission rates of patients with ambulatory sensitive conditions: an analysis comparing two managed care structures and indemnity insurance.

The utilization of financial incentives to limit the use of health resources by primary care physicians represents a common reimbursement strategy by managed care organizations. These arrangements are virtually nonexistent with indemnity insurance. This analysis compares the hospitalization rates of patients with low-acuity medical conditions--ambulatory sensitive conditions (ASCs)--among three groups receiving care from primary care physicians. The physicians were compensated under different reimbursement mechanisms, in which incentives for reduced resource utilization varied. The groups can be described as follows: (1) a capitated for-profit group practice in which the physician partners have a relatively high economic incentive for lower utilization (group I); (2) physicians providing care under the auspices of three separate independent practice associations, in which the associations are capitated but the physicians are paid on a discounted fee-for-service basis (the associations also were included in this group) (group II); and (3) physicians who service patients whose care continues to be paid for by traditional indemnity insurance (group III). Financial incentives in the third group cohort were believed to be low to intermediate, and the physicians were assumed to have had no economic incentives to restrain their use of healthcare resources. Additional data analysis examined the role of emergency department utilization among patients in the groups. Group I patients ages 25 to 44 were admitted for ambulatory sensitive conditions at a significantly lower rate than were patients in groups II or III--0.8/1,000, 2.7/1,000, and 2.9/1,000, respectively. No difference was apparent in admission rates between patients in groups II and III. Overall emergency department utilization rates were lowest in the group I capitated panel (70/1,000), much higher in the group II independent practice association panel (363/1,000) and highest in the group III indemnity panel (466/1,000). Each of these rates was significantly different from the other. Both the ED utilization rate and ambulatory sensitive condition admission rate may have been affected by differences in socioeconomic status among the patient panels in the three groups. The overall effect of this variable on the two admission rates could not be isolated.

Ambulatory Care↗
PubMedDate not supplied

Interprofessional referral patterns in an integrated medical system.

OBJECTIVE: To determine the interreferral patterns among physicians and complementary and alternative medicine (CAM) providers in an independent practice association integrated medical system. METHOD: Data from a 1-year period were collected on referral patterns, diagnosis, number of visits, cost, and qualitative aspects of patient care. The independent practice association provided care for approximately 12,000 patients. RESULTS: In the selected integrative network, there are those primary care physicians (PCPs) who refer and those who do not. Among those PCPs that refer to CAM, a preference is shown for a limited number of providers to whom they refer. Although doctors of chiropractic get more referrals, they are also more concentrated among selected providers than are doctors of oriental medicine. CONCLUSION: This study shows the interreferral patterns among the PCP and CAM providers working within an integrated medical system. One effect of being in the network for doctors of chiropractic and doctors of oriental medicine might be the possible interreferrals between each other.

Chiropractic↗
PubMed1998

Type of health care coverage and the likelihood of being screened for cancer.

OBJECTIVES: This study explored whether type of outpatient health coverage affected the likelihood of men and women aged 20 to 64 years receiving recommended cancer screening procedures. METHODS: Data from the 1989 and 1990 California Behavioral Risk Factor Surveillance Surveys were used to compare Pap smear, mammogram, fecal occult blood test, and proctoscopic examination rates for adults with three different types of private health care coverage (Group/staff model health maintenance organization, Independent Practice Association Model health maintenance organization, indemnity plan) and no outpatient health insurance. Logistic regression models were used to control for sociodemographic and health characteristics and whether individuals had a usual health care provider. RESULTS: Individuals with Group Model health maintenance organization coverage were significantly more likely than those with indemnity plans to have had recent cervical, breast, and colorectal cancer screening, whereas screening likelihood for those with Independent Practice Association model health maintenance organization coverage did not differ substantially from those with indemnity plans. Individuals with no outpatient coverage were less likely to be screened than those with outpatient coverage. The most consistently significant predictor across cancer screening procedures for both men and women was having a usual doctor who knew their medical history. CONCLUSIONS: Adults who had private outpatient insurance were more likely to undergo recommended cancer detection procedures than those who did not. Adults who belonged to a health maintenance organization, which emphasizes and pays for a broader spectrum preventive care, were more likely to receive Pap smears, mammograms, and fecal occult blood tests than those covered by indemnity plans. Receiving care primarily from one doctor significantly increased the likelihood of having screening procedures, irrespective of type of health plan.

Adult↗
PubMed1994

Physician, manage thyself. Texas doctors form IPAs to gain control of health-care delivery.

Mention managed care to most physicians, and the first thing they think of is loss of independence. Specifically, they associate managed care with having to answer to someone they may not agree with over how to treat their patients and run their practices. As managed care plans penetrate ever deeper into Texas, more and more physicians are looking for ways to minimize that loss of autonomy. And in many cases, they are finding it in the form of physician-driven independent practice associations (IPAs). Such associations are growing rapidly in virtually every corner of the state. Texas physicians, fearful of what health-system reform may bring to them and their patients and determined to control their fates, are becoming allies in IPAs. Texas, in fact, is quickly catching up with many urban states in the formation of IPAs. However, to meet specific local needs, several groups are introducing some unique forms of practice associations to the mix.

Delivery of Health Care↗
PubMed1999

The impact of relational activities on HMO organizational outcomes.

OBJECTIVE: To report the findings of an empirical study of health maintenance organization (HMO) organizational outcomes and relational activities in HMO-pharmaceutical manufacturer relations. STUDY DESIGN: A mailed survey of a national random sample of 273 HMOs. SUBJECTS AND METHODS: Data were obtained from 111 HMOs regarding their inter-organizational relations with a pharmaceutical manufacturer. Respondents reported on 3 relational activities (initiating behavior, flexibility, bidirectional communication) and 4 HMO organizational outcomes (long-term orientation, equity in sharing costs and benefits, commitment between partners, financial performance). Also, 3 control variables were assessed: number of enrolled beneficiaries, HMO type, and estimated annual acquisition costs of pharmaceuticals. Four multiple regression analyses were performed, each with one organizational outcome variable as the dependent variable. Measures of relational activities and the control variables were the independent variables in the regressions. RESULTS: The response rate was 40.7%. All 3 relational activities showed significant associations with HMO organizational outcomes. Two relational activities (bidirectional communication, initiating behavior) showed significant and positive associations with a long-term orientation. Independent practice association (IPA)-model HMOs were less likely to report a long-term orientation toward a pharmaceutical manufacturer than other types of HMOs (adjusted R2 = 0.40). Bidirectional communication and flexibility were significantly and positively associated with the equity of costs and benefits (adjusted R2 = 0.29). Commitment had significant positive associations with all 3 relational activities (adjusted R2 = 0.50). All 3 relational activities had significant positive associations with financial performance. HMOs with an annual acquisition cost > $2 million were less likely to report favorable financial performance associated with a pharmaceutical manufacturer than were HMOs with lower costs (adjusted R2 = 0.42). CONCLUSION: Relational activities, such as initiating behavior, flexibility, and bidirectional communication, can facilitate positive outcomes for HMOs. It is important for all parties interested in healthcare to recognize that managing care creates a tension between achieving patient outcomes and organizational outcomes.

Communication↗
PubMed2002

Provision of sexual health services to adolescent enrollees in Medicaid managed care.

OBJECTIVES: This Seattle project measured sexual health services provided to 1112 Medicaid managed care enrollees aged 14 to 18 years. METHODS: Three health maintenance organizations (HMOs) that provide Medicaid services for a capitated rate agreed to participate. These included a non-profit staff-model HMO, a for-profit independent practice association (IPA), and a non-profit alliance of community clinics. Analyses used health maintenance organizations' administrative data, chart reviews, and Medicaid encounter data. RESULTS: Health maintenance organizations provided primary care to 54% and well care to 20% of Medicaid enrollees. Girls were more likely than boys to have their sexual history taken or to be given condom counseling. Only 27% of sexually active girls were tested for chlamydia, with significantly lower rates of testing among those who spoke English as a second language. The nonprofit staff-model plan outperformed the for-profit independent practice association on most measures. CONCLUSIONS: Substantial room for improvement exists in sexual health services delivery to adolescent Medicaid managed care enrollees.

Adolescent↗
PubMed2006

Improving quality in Medicaid: the use of care management processes for chronic illness and preventive care.

BACKGROUND: Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care. OBJECTIVE: To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in California's Medicaid program and the factors associated with CMP adoption. METHODS: Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services. RESULTS: The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations. CONCLUSIONS: Physician and provider organizations heavily involved in California's Medicaid program are extensively engaged in preventive and chronic care management programs.

Adolescent↗
PubMed2000

The effects of structure, strategy and market conditions on the operating practices of physician-organization arrangements.

Research to date has documented weak or inconsistent associations between market and organizational factors and the adoption of physician-organization arrangements (POAs) (e.g. physician-hospital organizations, management service organizations and independent practice associations) designed to increase physician integration. We argue that POAs may mask considerable variation in how these entities are operated and governed. Further, because the operating policies and practices of POAs are likely to influence more directly the behaviour of physicians than the structural form of the POA, they may be more sensitive to the market and organizational contingencies that encourage integration. This study attempts to test empirically the relative effects of POA type and market, strategic and organization factors on the operating policies and practices of market-based POAs. Results suggest that type of POA, and market, strategic and organizational factors affect risk sharing, physician selection practices, physician monitoring practices and ways in which monitoring information is used to influence physician behaviour in POAs.

Health Care Sector↗