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Results for “Independent Practice Associations”

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PubMed1993

Outcomes for adult outpatients with depression under prepaid or fee-for-service financing.

OBJECTIVE: To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties. METHOD: Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States. RESULTS: Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall. CONCLUSION: Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

Adult↗

PubMed1993

Comparing low-severity hospital admissions in IPA HMOs and indemnity-type programs.

This study compares the proportion of low-severity hospital patients in independent practice association (IPA) HMOs and indemnity-type programs. The length of stay of such low-severity patients is also studied. Admissions of IPA patients under age 65 to ten hospitals are compared with admissions to the same hospital of patients covered by Blue Cross and Blue Shield plans or commercial insurance programs. Admissions to the adult medical service for the eight most frequently occurring DRGs with 5 percent or more patients in the low-severity category are included. A Logit model of the probability of low-severity admission controlling for age, sex, DRG, and hospital shows no significant IPA effect. However, a multiple regression model shows that the IPAs have significantly lower average length of stay for these low-severity patients.

Concurrent Review↗

PubMed1989

Effect of a gatekeeper plan on health services use and charges: a randomized trial.

A randomized trial was conducted to determine the effectiveness of a health care plan which uses physicians as gatekeepers to control health services use and charges. New enrollees in United Healthcare (UHC), an independent practice association, were randomly assigned to the standard UHC plan requiring a gatekeeper, or to an alternate plan with equal benefits but without a gatekeeper. Individuals in both plans were similar in demographic characteristics, perceived health status, and other health insurance coverage. The gatekeeper plan had 6 percent lower total charges per enrollee than the plan without a gatekeeper. There were minor differences in hospital use and charges. Ambulatory charges were $21 lower per person per year in the plan with a gatekeeper (95% CI = -39.9, -2.1) and these were due to .3 fewer visits to specialists (95% CI = -0.50, -0.10). We conclude that a health plan which incorporates incentives and penalties for physicians to act as gatekeepers can reduce the cost of ambulatory services by limiting specialist visits.

Adolescent↗

PubMed1998

Primary care reform: a three country comparison of 'budget holding'.

Governments in most developed nations have been looking to organisational and financial reform of health systems over the last decade. Although the structure and problems of the health care sector in each country may differ, with countries correspondingly adopting different reform agendas, there has been some element of commonality in reforms: that of (managed) competition. Of particular importance in such reforms has been the strengthening of primary care. General practitioners and primary care physicians, as 'gatekeepers' to the health system, are increasingly being called upon to be accountable; not only for their patients' health but also for the wider resource implications of any treatments prescribed. In some countries this role has been formalised through establishing 'budget holding' for general practitioners and primary care physicians, for example, through general practice 'fund holding' in the UK, Health Maintenance Organisations in the USA, and Independent Practice Associations in New Zealand. This paper examines: (i) what such budget holding seeks to achieve; (ii) the effectiveness of the budget holding experience to date in achieving these objectives; and (iii) factors which appear to determine the success of budget holding in achieving its objectives.

Budgets↗

PubMed2004

What are the facilitators and barriers in physician organizations' use of care management processes?

BACKGROUND: Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs. METHODS: Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities. RESULTS: Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy. DISCUSSION: Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.

Asthma↗

PubMed2000

Preemptive financial strategies help IPAs avoid insolvency.

The 1999 collapse in California of practice management giants FPA Medical Management, Inc. and MedPartners, Inc. has caused healthcare provider organizations, particularly independent practice associations (IPAs), to examine critical issues related to financial solvency. Problems such as declining membership, ineffective management, weak contracting, and lack of strategic vision frequently are encountered by troubled provider organizations. The common thread that runs through IPA failures is a combination of unreliable accounting data and inadequate reporting systems. This lack of satisfactory financial and reporting information impairs the ability of the provider group to maintain sufficient funds to cover expenses and pay physicians. Successful, financially stable provider networks use well-defined reporting procedures based on fundamental accounting and financial concepts, as well as a sound methodology for measuring and calculating claims liability estimates. In California, new regulations aimed at encouraging provider organizations to assume preemptive financial strategies are in the process of being adopted. IPAs in every state should consider reviewing these regulations as benchmarks by which to assess their financial procedures.

Accounting↗

PubMed1999

Pharmacy risk: is it in your future?

This article discusses how Sutter Health's affiliated medical groups and independent practice associations (IPAs) prepared for entering a pharmacy risk agreement. It should serve as a primer for those providers contemplating pharmacy risk and is written in lay terms. Providers who expect not just to survive, but to thrive, in a capitated environment must approach pharmacy risk agreements with extreme caution.

Actuarial Analysis↗

PubMed1989

Differences in inpatient resource use by type of health plan.

Approximately 50% of the annual increase in hospital costs comes from increased resource use per hospital admission. Health maintenance organizations (HMOs), given their fixed financial resources for patient care, have an incentive to constrain their enrollees' use of hospital resources. Our analysis investigates differences in length of stay, total charges, and the ancillary to total charge ratio for hospitalized patients in network HMOs, independent practice associations (IPAs), and fee-for-service (FFS) health plans in the Twin Cities from 1982 to 1984. Network HMO patients in several diagnostic categories are found to use significantly fewer resources, once hospitalized, than patients in either IPA or FFS plans. This difference may give network HMOs a competitive advantage in the market for health plans.

Group Practice↗

PubMed1995

Small-area variations in the treatment of prevalent medical conditions: a comparison of three cities in the Northeast.

This article presents a small-area variation study that examines utilization differences for primary care physicians (PCPs) in treating a homogeneous set of prevalent medical conditions. The study used secondary data collected over a 24-month period from a large, Northeastern region independent practice association. The diagnostic cluster methodology was used to examine geographic differences for PCPs in treating prevalent medical conditions. This methodology groups International Classification of Diseases, 9th revision (ICD-9), codes into diagnostic clusters based on clinical homogeneity with respect to generating a similar clinical response from the physician. For each diagnostic cluster, diagnostic episode clusters (DECs) were formulated. Each DEC links all services incurred in treating a patient's medical condition within a specific period of time. Differences in use rates across small areas were tested using t tests. The data showed little variation in the physician office visit rate across small areas. However, services generated from these office visits exhibited large rate variations. The most significant small-area differences were for hospital inpatient days and surgical procedures. Pattern-of-treatment differences exist across small areas for the homogeneous set of prevalent medical conditions treated by PCPs.

Age Factors↗

PubMedDate not supplied

How different is California? A comparison of U.S. physician organizations.

Data from a national study of medical groups and independent practice associations are used to examine the extent to which California physician organizations are different from physician organizations in the rest of the United States. California physician organizations are different in many ways: most notably, they are more likely to have external incentives to improve quality and more likely to use recommended care management processes for treating patients with chronic illnesses. The implications of these differences for policy and practice are discussed.

California↗

PubMed2006

The Federal Trade Commission, clinical integration, and the organization of physician practice.

This article examines Federal Trade Commission (FTC) policy--in particular, the agency's controversial 1996 statements on clinical integration--toward joint negotiations for nonrisk contracts with health plans by physicians organized into independent practice associations (IPAs) and (with hospitals) into physician-hospital organizations (PHOs). The article concludes that the policy is consistent with anti-trust principles, consistent with current thinking on the use of organized processes to improve medical care quality, specific enough to provide guidance to physicians wanting to integrate clinically, and general enough to encourage ongoing innovations in physician organization. The FTC should consider stronger sanctions for IPAs and PHOs whose clinical integration is nothing more than a sham intended to provide cover for joint negotiations, should give the benefit of the doubt to organizations whose clinical integration appears to be reasonably consonant with the statements, and should clarify several ambiguities in the statements. Health plans should facilitate IPA and PHO efforts to improve care by rewarding quality and efficiency and by providing clinically integrated organizations with claims information on individual patients. Though creating clinically integrated organizations is difficult and expensive, physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patients.

Antitrust Laws↗

PubMedDate not supplied

Medical group bankruptcies: an emerging problem.

This article explores the reasons why medical group practices and independent practice associations are filing for bankruptcy with increasing frequency. The problem stems from capitation payments by managed care organizations that are not sufficient to cover the costs of providing necessary care. The result is the dislocation of patients who have to find a new provider and providers who have to find a new practice setting. This article suggests that if the managed care industry could adopt clinical risk adjustment as a mainstay of physician compensation, medical groups and IPAs would have a far better chance of managing patient risk more successfully under capitation.

Bankruptcy↗

PubMed1996

Models of managed care: the potential power of the IPA.

As managed care changes medical practice organization, Individual or Independent Practice Associations (IPAs) have theoretically superior attributes as compared with the more centralized large integrated multispecialty group on the one hand, and the less centralized "direct gatekeeper" model on the other. IPAs preserve the small, entrepreneurial, efficient, personal practice model of care delivery, while grafting on necessary business, informational, and care rationalizing functions at the collective level. The IPA also offers practitioners political leverage against the centralizing forces, particularly if the IPA establishes multiple HMO and PPO relationships. Physician autonomy will be best served if practices are allowed multiple IPA memberships. Competition in this model will be multicentric.

Economic Competition↗

PubMed1994

Perception of the need for removal of impacted third molars by general dentists and oral and maxillofacial surgeons.

This prospective study investigated the influence of professional training and method of payment on how dental practitioners planned extraction of impacted third molars. The subjects were four groups of dental practitioners in metropolitan Chicago: 1) general dentists in traditional fee-for-service practice; 2) general dentists who were members of a preferred provider organization; 3) general dentists who were members of an Independent Practice Association model of a capitation system; and 4) oral and maxillofacial surgeons, all of whom were in fee-for-service practice. A carefully selected and trained professional actress, in good health, with four unerupted, impacted, and asymptomatic third molars, brought her recently taken full mouth periapical and panoramic radiographs to randomly selected dentists for a consultation. The number of planned extractions (no treatment was ever done) was compared. Data showed that oral and maxillofacial surgeons suggested significantly more extractions than capitation dentists and the average of all general dentists, combined.

Adult↗

PubMed2002

Missed opportunities for prevention of osteoporotic fracture.

BACKGROUND: Osteoporotic fracture is a growing public health problem burden to society. Despite the importance of physician practices in preventing it, relatively little is known about the osteoporosis-related practices of US physicians. METHODS: A total of 1500 female members of a Connecticut independent practice association model health plan (aged 40-69 years) were surveyed to identify women's receipt of osteoporosis-related services (eg, prevention counseling, bone mineral density [BMD] testing, and communication about treatment options). These findings were compared with recommendations of the US Preventive Services Task Force and the National Osteoporosis Foundation. We received 1007 completed questionnaires, for a response rate of 69%. RESULTS: Only 49% of the sample reported that a health care provider ever discussed osteoporosis with them. In multivariate analyses, women with multiple risk factors were not more likely than other women to have been counseled about osteoporosis and its prevention, although those with an osteopenia/osteoporosis diagnosis were. In contrast to National Osteoporosis Foundation recommendations, only a small minority of high-risk women (12%-34%) had their BMD tested. Although most women with an osteopenia/osteoporosis diagnosis reported receiving information on estrogen replacement therapy, calcium, and weight-bearing exercise, fewer reported receiving information on pharmaceutical alternatives to estrogen (33%) and vitamin D (20%). CONCLUSIONS: The main trigger to physician counseling of women about osteoporosis and its prevention is an osteopenia/osteoporosis diagnosis. Women with multiple risk factors for osteoporosis are not being identified for preventive counseling interventions or BMD testing.

Adult↗

PubMed1997

Variations in cataract extraction rates in Medicare prepaid and fee-for-service settings.

OBJECTIVE: To compare rates of cataract extraction in 2 prepaid health settings and in traditional fee-for-service (FFS) settings. DESIGN: A cross-sectional analysis using 1993 health maintenance organization (HMO) Medicare claims and encounter files, the Health Care Financing Administration (HCFA) 5% Medicare Part B provider/supplier file, and the HCFA October 1992 100% Medicare population file. SETTING: Southern California Medicare FFS settings and the staff-model and independent practice association (IPA) plans of a large California HMO. PATIENTS: 1993 Medicare beneficiaries aged 65 years and older. The study included 43387 staff-model HMO enrollees, 19050 IPA enrollees, and 47 150 FFS beneficiaries (a 5% sample of all Southern California FFS beneficiaries). MAIN OUTCOME MEASURE: Age and risk-factor adjusted rates of cataract extraction per 1000 beneficiary-years. RESULTS: After controlling for age, sex, and diabetes mellitus status, FFS beneficiaries were twice as likely to undergo cataract extraction as were prepaid beneficiaries (P<.01). Female FFS beneficiaries were nearly twice as likely to undergo the procedure as were male FFS beneficiaries (P<.001); there were no extraction rate differences by sex in the prepaid settings. CONCLUSION: Because of the potential implications for vision care in the elderly, the significantly different rates of cataract extraction in FFS and prepaid settings warrant further clinical investigation to determine whether there is overuse in FFS vs underuse in prepaid settings. Such investigations must assess the appropriateness of cataract surgery by evaluating its use relative to clinical need.

Age Distribution↗

PubMed1988

A primer on how to analyze contracts and avoid the traps.

Contracts from preferred provider organizations, health maintenance organizations, independent practice associations, and managed health plans present numerous problems for primary care physicians. The ability to understand the terms and conditions is an essential part of the practice of medicine today. Additionally, physicians need to involve experts in the preparation of counterproposals that will render contracts fair and equitable for physicians. The blind acceptance of a contract may dramatically increase a physician's liability exposure. Although contracts have become a permanent fixture in the current health care delivery environment, physicians can formulate informed and intelligent responses. They and their office personnel can learn basic analysis techniques of such documents that will aid in surviving the onslaught of contracts.

Contract Services↗

PubMedDate not supplied

A reforming accountability: GPs and health reform in New Zealand.

Over the last ten years or so, many countries have undertaken public sector reforms. As a result of these changes, accounting has come to play a more important role. However, many of the studies have only discussed the reforms at a conceptual level and have failed to study how the reforms have been implemented and operated in practice. Based on the work of Lipsky (1980) and Gorz (1989), it can be argued that those affected by the reforms have a strong incentive to subvert the reforms. This prediction is explored via a case study of general practitioner (GP) response to the New Zealand health reforms. The creation of Independent Practice Associations (IPAs) allowed the State to impose contractual-accountability and to cap their budget exposure for subsidies. From the GP's perspective, the IPAs absorbed the changes initiated by the State, and managed the contracting, accounting and budgetary administration responsibilities that were created. This allowed individual GPs to continue practising as before and provided some collective protection against the threat of state intrusion into GP autonomy. The creation of IPAs also provided a new way to manage the professional/financial tension, the contradiction between the professional motivation noted by Gorz (1989) and the need to earn a living.

Budgets↗