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PubMedDate not supplied

Physician organization in California: crisis and opportunity.

Many of the 250 physician organizations that provide care to California's sixteen million health maintenance organization enrollees are in a state of crisis, squeezed between constrained revenues, rising practice costs, and consumer sentiment that favors unconstrained choice over integrated delivery. Medical groups and independent practice associations are retrenching to their core geographic areas, reducing capitation for drug benefits and hospital services, and abandoning dreams of displacing health plans. Consolidation is accelerating in some areas, as medical groups join with hospitals to extract higher payment rates from insurers and employers. The conjunction of consumerism and premium inflation creates new opportunities for organizations that truly can manage health care, but the challenges roiling California's medical groups may preclude meaningful efforts to seize the initiative.

California↗

PubMed2002

Variation in patient-reported quality among health care organizations.

Health care quality measurement initiatives often use health plans as the unit of analysis, but plans often contract with provider organizations that are managed independently. There is interest in understanding whether there is substantial variability in quality among such units. We evaluated the extent to which scores on the Consumer Assessment of Health Plans Study (CAHPS) survey vary across: health plans, regional service organizations (RSOs) (similar to independent practice associations [IPAs] and physician/hospital organizations [PHOs]), medical groups, and practice sites. There was significant variation among RSOs, groups and sites, with practice sites explaining the greatest share of variation for most measures.

Adolescent↗

PubMedDate not supplied

Physician organization and care management in California: from cottage to Kaiser.

Data from a survey of practicing physicians in California's thirteen largest urban counties were used to ascertain differences in care management processes, financial incentives for quality, and practice pressures by type of practice setting. Physicians in the Permanente medical groups have adopted and value quality-oriented, system-level care management tools to a much greater degree than physicians in independent practice association (IPA) networks or traditional "cottage-industry" practices. Our findings raise disturbing questions about how the health system will close the "quality chasm" in medical care without transforming the underlying organization of physician practices.

California↗

PubMed2005

Doctor group sues to keep capitation arrangement.

An independent practice association has sued Humana Kansas City Inc. over the health plan's decision to terminate its capitated contract. The suit alleges breach of contract and seeks an injunction to keep the flow of capitated dollars coming.

Capitation Fee↗

PubMed1994

Health plan choice in the Twin Cities Medicare market.

This paper examines the relationship between characteristics of Medicare beneficiaries and their choice of health plan in the Twin Cities during 1988. This analysis provides the first comparison of beneficiaries in the basic fee-for-service (FFS) Medicare sector (without a supplementary policy) to beneficiaries in the FFS sector with a supplementary policy, enrollees in independent practice associations (IPAs), and network health maintenance organizations (HMOs). The site and time period are important because there were five large, mature HMOs with TEFRA-risk contracts operating at that time, enrolling 50% of Medicare beneficiaries in the market area. We find that the oldest, poorest and, to a lesser extent, the sickest Medicare beneficiaries were most likely to have basic FFS Medicare coverage without supplementary insurance. The youngest enrollees are found in network HMOs. The availability of group coverage and premium subsidies are positively associated with choice of FFS with a supplementary policy. Government policy concerning Medicare HMO premiums appears to contribute to the poorest beneficiaries facing the highest out-of-pocket costs.

Age Factors↗

PubMed1995

Hospitals versus physicians, POs versus PHOs: the providers' struggle for control of managed care contracting.

The great majority of U.S. hospitals are at one stage or another of physician-hospital organization (PHO) formation, in an attempt to accomplish hospital-physician integration. Since early 1994, however, significant numbers of physicians have begun to form their own organizations and confederations. The physician organization (PO), a more highly evolved form of the independent practice association, usually covers a wide geographic area, and it can cross hospital boundaries. Founders of the PO nearly always wish to position the organization to negotiate "master contracts" directly with payers and employers, rendering hospitals mere subcontractors. This article examines the evolution of physician attitudes about PHOs and POs, and also gives insight into the details of PO formation. The author outlines barriers to PO formation, and draws a picture of a momentous industrywide struggle for control between physicians and hospitals.

Capitation Fee↗

PubMedDate not supplied

Messenger model IPAs need caution in managed care.

Messenger model independent practice associations (IPAs) are a popular choice for physicians coming to together to improve payer negotiations. However, it is easy for such models to run afoul of antitrust regulations, as did a messenger model IPA in Tampa, Fla. The following is a discussion of this case. You should be able to use it as a guide if and when you are ever involved in a messenger model IPA situation. This article also will provide tips and strategies for working in the messenger model IPA format.

Antitrust Laws↗

PubMed1997

Managed care, capitation, and the future of nephrology.

Within the next decade, it is predicted that more than 90% of the United States population will receive its health insurance through managed care. Capitation will be the reimbursement mechanism to health care providers as the major way of controlling costs. Currently, managed care has had little experience with capitation payments for chronically ill patients, who consume large financial and physical resources. The end-stage renal disease (ESRD) population represents a vulnerable group of patients, and their care may be compromised in a capitated environment. Nephrologists will need to serve as advocates for ESRD patients through a mechanism of quality of care, driven by a continuous quality improvement model. Cost-effective delivery of care will occur as nephrologists join together to form Independent Practice Associations (IPAs). In this article, the role of a nephrologist in a capitated environment is outlined in detail, and background for the basis of managed care growth is provided as a framework for understanding the change in our health care delivery system. After formation of a nephrology IPA, there will most likely be a linkage with a management service organization (MSO). A business plan driven by the highest principles will allow nephrologists to work together as a cohesive force in accepting global risk capitated contracts. The starting point is for ESRD care, and the future includes pre-ESRD care.

Capitation Fee↗

PubMed1987

Medicare HMOs. The new kid on the block.

Medicare HMOs may not be the ultimate answer to geriatric care, but they continue to grow in number and are becoming increasingly popular among the elderly. Independent practice association (IPA) groups are the fastest growing type. Problems concerning quality of care and cost, exemplified in the extreme by the recent case of the International Medical Centers HMO in Florida, have illustrated the need for greater regulation of Medicare HMOs by the Health Care Financing Administration. The author outlines the advantages and disadvantages of a prepaid health plan for elderly patients, as well as for the physicians who are members. Three methods of creative geriatric programming are suggested; these would promote continuity of care and decrease hospitalization rates, yet pose no risk to patients.

Aged↗

PubMed1995

A glimpse of an IPA as a living system.

Independent practice association (IPA) model health maintenance organizations (HMO's) represent one of the fastest growing segments of managed care in the United States. IPA's have unique organizational characteristics which thwart efforts to function as a unified whole, particularly where quality of care programs are concerned. Living systems theory was employed as a method to identify subsystems and critical processes within an IPA model HMO in rural California. The application of living systems theory in this way provided insights into the quality of care program within the IPA, which could eventually lead to a redesign of critical processes within the entire system.

Health Maintenance Organizations↗

PubMed2003

IS/IT the prescription to enable medical group practices attain their goals.

The US spends significantly more money as a percentage of GDP on health care than any other OECD country and more importantly, this amount is anticipated to increase exponentially. In this high cost environment, two important trends have occurred: (1) the movement to managed care, and (2) large investments in Information Systems/Information Technology (IS/IT). Managed care has emerged as an attempt to provide good quality yet cost effective health care treatment. Its implications are not well discussed in the literature while, its impact on different types of medical group practices is even less well understood. The repercussions of the large investments in IS/IT on the health care sector in general and on the medical group practice in particular, although clearly of importance, are also largely ignored by the literature. This study attempts to address this significant void in the literature. By analyzing three different types of group practices; an Independent Practice Association (IPA), a Faculty Practice and a Multi Specialty Group Practice in a managed care environment during their implementation of practice management/billing systems, we are able to draw some conclusions regarding the impacts of these two central trends on health care in general as well as on the medical group practice in particular.

Contract Services↗

PubMedDate not supplied

Managed care in New Zealand: managed competition or managed collaboration?

Managed care is making major progress in New Zealand through independent practice associations (IPAs) now representing more than 50% of general practitioners. It is also being implemented by community groups, especially Maori, who see great potential in improving the health status of their people through this strategy. However, a significant conflict appears to be developing between achieving managed care through managed competition on the one hand and managed collaboration on the other. There appear to be fundamental flaws in the concept of managed competition. Evidence is emerging that managed collaboration is far more likely to be effective in achieving the Government's goals of improving health status and access and more cost-effective healthcare.

Budgets↗

PubMedDate not supplied

Utility scores for dimensions of clinical laboratory testing services from two purchaser perspectives.

Information is critical for making health-care purchasing decisions. Identifying the importance of dimensions and criteria used by purchasers of clinical laboratory testing services is the second step in the development of a report card to evaluate such services. The purpose of this study was to quantify the utility--the importance of four dimensions: access, cost, quality, and service--for two stakeholders of clinical laboratory testing services. Data were collected using a survey of hospital laboratories, as well as independent practice associations (IPAs) and preferred provider organizations (PPOs) that purchase clinical laboratory testing services. Although valued differently with respect to the magnitude of the utility score, both stakeholders rate quality and cost as first and second in importance. Managed-care organizations rate access and service as third and fourth in importance. Hospital laboratories consider service third in importance, yet with a similar utility score as that for managed-care organizations. Ten of 19 criteria (52.6%) were rated differently by the stakeholders. Using these utility scores for the dimensions and the criteria serves as a preliminary scoring system for a report card to evaluate clinical laboratory testing services.

Clinical Laboratory Techniques↗

PubMedDate not supplied

Beyond HMOs: understanding the next wave of change in health-care organization.

The growing strength of managed care has diminished the financial and clinical autonomy of many orthopaedic surgeons. In part to offset these negative trends, new relationships are being developed to define doctors' methods of contracting with health-maintenance organizations. These include physician practice management companies (PPMs), independent practice associations, management service organizations, and physician-sponsored organizations. Each entity offers distinct advantages and disadvantages. While the PPM is the most popular new vehicle to offset adverse market trends, it carries with it some of the greatest potential pitfalls. In every case, before negotiating to join one of these new entities, it is important for a physician to have a solid understanding of the competing claims made by each entity, as well as insight into the fiscal health of the particular company in question. For some doctors, these arrangements offer a solution to current woes. For others, PPMs interpose another meddlesome intermediary in a market already bloated by layers of bureaucracy.

Contract Services↗

PubMedDate not supplied

Beating the odds: reducing the risk of not being paid by HMOs and IPAs.

Physicians are having increasing problems getting paid by HMOs, independent practice associations and other payers. This article discusses what practices should investigate about payers, and guidelines for negotiating protections in contracts with payers. Even if certain clauses cannot be negotiated, it is important that providers be aware of potential traps in the contract. By using these guidelines, physicians will be able to negotiate better contracts or decide that no contract is better than a bad contract.

Guidelines as Topic↗

PubMedDate not supplied

HMO market structure and performance: 1985-1995.

This paper estimates the effect of market structure on hospital days and ambulatory visits in independent practice associations (IPAs) and group-model health maintenance organizations (HMOs) where market structure is measured by HMO penetration and the number of HMOs operating in a market. There was a steady decline in inpatient use in HMOs during the study period and a steady increase in use of ambulatory care. In multivariate analyses, inpatient use is significantly higher in IPAs, but there is no difference in ambulatory use. As HMO penetration increases and the number of HMOs increases, group-model HMOs have lower hospital use and greater ambulatory use. In contrast, use of both inpatient and ambulatory care decreases in IPAs but only at high levels of penetration and numbers of competitors.

Ambulatory Care↗

PubMedDate not supplied

Transmission of financial incentives to physicians by intermediary organizations in California.

Many U.S. physicians participate in provider-sponsored organizations that act as their intermediaries in contracting with managed care plans, particularly where capitation contracts are used. Examining a survey of 153 intermediary entities in California, we trace the cascade of financial incentives from health plans through physician organizations to primary care physicians. Although the physician organizations received the vast majority (84 percent) of their revenues through capitation contracts, most of the financial risk related to utilization and costs was retained at the group level. Capitation of primary care physicians was common in independent practice associations (IPAs), but payments typically were restricted to primary care services. Thirteen percent of medical groups and 19 percent of IPAs provided bonuses or withholds based on utilization or cost performance, which averaged 10 percent of base compensation.

California↗

PubMed1990

The quality of ambulatory care in Medicare health maintenance organizations.

The quality of ambulatory care received by Medicare recipients who enrolled in health maintenance organizations (HMOs) was compared to the care received by fee-for-service (FFS) Medicare recipients, in a quasi-experimental, non-randomized design. Both samples were drawn from the four major geographic areas in the country, and included two types of HMO practices: staff/group models, and independent practice associations (IPAs). A panel of expert physicians developed criteria for evaluating ambulatory care, and medical record abstractions using these criteria were performed on 1,590 outpatient records: 777 FFS and 813 HMO (441 staff/group, 372 IPA). While individual items of medical histories and physical examinations were performed most often for staff/group HMO patients and least often in FFS patients, odds ratios (OR) for performance in staff/group HMO patients were particularly large for health maintenance items: tonometry (OR = 8.4), mammography (OR = 2.7), pelvic examination (OR = 5.3), rectal examination (OR = 2.9), fecal occult blood test (OR = 3.3). The results suggest that recommended elements of routine and preventive care are more likely to be performed for Medicare enrollees in staff/group HMOs than in FFS settings.

Aged↗