Physician Integration & Alignment : IPA, PHO, ACOs, and Beyond book cover
1st Edition

Physician Integration & Alignment
IPA, PHO, ACOs, and Beyond

ISBN 9781439813089
Published November 5, 2012 by Productivity Press
260 Pages 12 B/W Illustrations

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Book Description

Today, with physician and hospital reimbursement being cut and tied to quality incentives, physicians and health plans are revisiting the concept of integration. Payers are demanding that the industry do more with less without sacrificing quality of care. As a result, physicians again find themselves integrating and aligning with hospitals that have the resources they lack or must develop together.

Written by an acknowledged expert in the field of physician integration and managed care contracting, Physician Integration & Alignment: IPA, PHO, ACOs, and Beyond examines physician integration and alignment in the current healthcare market. It outlines the common characteristics of integrated groups and various organizational structures, and also explains how you can avoid making the same mistakes of the past. Filled with suggestions and ideas from successfully integrated practices, the book:

  • Identifies industry drivers for the resurgence of integrated models and the need for aligned models
  • Provides a look at the common characteristics of integrated and aligned groups and how the components can work together
  • Discusses antitrust and other regulatory concerns present when considering the right organizational and management structure
  • Offers time- and money-saving checklists, lessons learned, models, and templates—saving you thousands of dollars in consulting fees

Maria K. Todd provides readers with the vision and practical tools needed to organize their business entities in a manner that will maximize economic clout and provide quality of care for both the hospital and physician group. This much-needed resource includes helpful insights on topics such as declining physician reimbursement, declining margins, physician shortages, physician-hospital competition, rising practice investment requirements, the return to capitation as a payment mechanism, and recent changes in the relationships between physicians and health systems.

Maria currently is the principle of the largest globally integrated health delivery system in the world with over 6,000 hospitals and 85,000 physicians spanning 95 countries. She has developed more than 200 integrated and aligned IPAs, PHOs, ACOs, MSOs and healthcare clusters in her career.

Table of Contents


The Goals and Objectives of Physician Alignment and Integration: Form Follows Function

Independent Practice Associations (IPAs)
Second-Generation IPAs
     Step 1
     Step 2
     Step 3
     Step 4
Financing and Managing the IPA
Picking Your Consultants
Operations Management for the IPA
     Administrative Staffing for the IPA
     Governance Issues for the IPA
     Start-Up Capital
     Solvency Standards
     The Steering Committee
     The Bylaws Committee
     Membership Committee
     Utilization Management Committee
     Quality Assurance (QA) Committee
     Finance Committee
     Credentialing Committee
     Other Concerns Relevant to Prequalification for Membership
     Access Issues
     Medical Records Review
     Recertification and Recredentialing
     Grievance Policies
     Other Operational Issues

Physician Hospital Organizations (PHOs)
PHO Revenue Allocation
PHO Direct Contracting
Negotiation and Projection Hindrances
Differences in Administrative Style among Members
Managed Care Contracting with Payors
Governance Issues: Control
Medicare Anti-Kickback and Practice Acquisitions

Accountable Care Organizations (ACOs)

Management Services Organizations (MSOs)
Three Basic Elements of MSOs


The Steering Committee Gets Busy: Step-by-Step Instructions for What to Do and How to Do It
Steering Committee Task List
     Background/Understanding of Task
          Develop a Statement of the Committee’s Purpose
     Development of the Shared Vision
Organizational Development of the IPA
Organizational Development of the MSO Required of the Steering Committee
Market Focus
Development of a Business Plan

Corporate Form: A Myriad of Choices
Organizing the Steering Committee
     The Multi-Specialty IPA or PHO
     The Single-Specialty IPA or PHO
     The Management Services Organization (MSO)
     General Partnerships
          Disadvantages of General Partnerships
     Limited Partnerships
          Advantages of Limited Partnerships
          Disadvantages of Limited Partnerships
     Advantages of Corporations
     Disadvantages of Corporations
The Subchapter S Corporation
     Disadvantages of S Corporations
Double-Taxation Considerations
The Limited Liability Corporation (LLC)
Other Concerns of the Steering Committee

Guidance for the Utilization Management and Quality Improvement Steering Committees
First Things First
     Utilization Management Program Outline
     Quality Improvement and Assurance Program
     Activities to Study and Frequency of Each Study
          Frequently Asked Questions by the Health Plans (Don’t be caught without an answer!)
     Documentation Quality
     Adverse Outcome Review

Network Financial Management: The Intersection of Finance, Utilization Management and Capitated Risk Management
Finance Reports
Utilization Management Reports
Additional Monitoring Reports

Provider Organization Credentialing and Privileging
Typical Managed-Care Provider Organization Representations and Warranties
Provider Expectations
Practitioner Requirements
Non-Physician and Provider Requirements
The Credentialing Process
Delegated Credentialing

The Credentialing Committee’s Assignment: What to Do and How to Do It
Due Diligence in Credentialing
     Vicarious Liability
     Master and Servant Liability
     Ostensible Agency
Structuring a Good Credentialing Policy
"Provider Application for Credentialing"
     General Information
     Licensing/Certifications/Registration Numbers
     Hospital Privileges
     Professional Liability Coverage (at the time this application is completed)
     Disciplinary Actions
     Professional References
     Office Information

Antitrust Compliance Task Force: Understanding Antitrust Concerns for Provider Networks
What Are the Antitrust Laws?
Terms Used in the Guidelines
The Federal Guidelines of Antitrust Enforcement Policy in Healthcare
     Statement 4: Providers’ Collective Provision of Non-Fee-Related Information to Purchasers of Healthcare Services
     Statement 5: Providers’ Collective Provision of Fee-Related Information to Purchasers of Healthcare Services
     Statement 6: Provider Participation in Exchanges of Price and Cost Information
     Statement 7: Joint Purchasing Arrangements among Healthcare Providers
     Statement 8: Physician Network Joint Ventures
Use of the Messenger Model to Negotiate an Agreement with a Payor
     Characteristics of the Arrangement
     Legality of the Arrangement
Variations on the Messenger Model
Non-Integrated Network that Presents and Discusses Non-Fee Related Information and Uses the Messenger Model for Financial Arrangements
     Case Scenario
     Variation on the Arrangement
     Variation on the Arrangement
Qualified Managed Care Plans (QMCPs)
     How the QMCP Concept Came About
     Substantial Financial Risk Must Be Shared
Agency Analysis of Physician Network Joint Ventures that Fall Outside These Antitrust "Safety Zones"
Statement 9: Multi-Provider Networks
Shared Substantial Financial Risk
No Sharing of Financial Risk
Rule of Reason Analysis
     Selective Contracting
     Messenger Models
Useful Addresses and Telephone Numbers

Business Plan Development
Model Business Plan
The Executive Summary
     Company Direction
     Company Overview
     Capital Requirements
     Management Team
     Service Strategy
     Market Analysis
     Customer Profile
     Marketing Plan
     Marketing Strategy
     Advertising and Promotion
     Public Relations
     Financial Plan
Financial Plan
     Gross Profit Analysis
     Budget—Income Statements
     Balance Sheets
     Cash Flows Statements
     Break-Even Analysis
     Capital Requirements
     Use of Funds
     Exit/Payback Strategy
Keeping Your Infant Business Competitive: Non-Disclosure Agreements
Sample Non-Disclosure Agreement

Guidance for the IT Committee


Contracting with Payer Organizations

Contracting for Capitation and Bundled ServiceArrangements
Capitation Demographics Analysis
Dealing with Unpredictable and Unmanageable Risk Reinsurance
Dividing the "Pie"
Fee Schedules
Case Rates
     The Moral of the Story

Understanding Capitation Performance Guarantees

Considerations for Reinsurance Purchases for the Integrated
Health Delivery System
Covering the Remainder
Policy Key Features
     What to Consider when Buying Capitated Stop Loss/Reinsurance from a Private Insurer
     What to Consider when Buying Coverage from an Insurance Company
Dealing with Managing General Underwriters (MGUs)
     What to Consider when Purchasing from a Managing General Underwriter

Opportunities in Delegated Utilization Management and Claims Management for the MSO
Claims Payment Responsibilities (Delegated ClaimsPayment)
Utilization Management (Delegation of UtilizationManagement)

Beyond Traditional HMO and PPO Contracts: Direct Contracting with Employer-Sponsored Health Benefit ERISA Plans
More ERISA Plans than NCQA-Accredited HMOs and PPOs
     Demystifying Covered and Non-Covered Services
Wrap SPD Document Requirements

Volunteer Committee Survey Form
Sample LLC Document Set
How to Hire the Right Consultants

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Maria K. Todd has been involved in the healthcare industry for most of her working life. She has maintained an independent consulting practice since 1986 and has offered guidance to thousands of clients worldwide in the domains of managed care, healthcare revenue cycle, hospital and medical group administration, physician employment contracting, organizational development, medical tourism, healthcare benefits management, and value-based purchasing.

With her multifocal background and education as a healthcare business administrator, health law paralegal, surgical nurse, HMO provider relations coordinator and certified mediator, and a licensed insurance producer, she has expertise in niche areas such as full-risk capitation, managed-care contracting, and negotiating on behalf of payers, providers, and employers. She brings a wealth of specialized knowledge to the development, implementation, and operation of IPAs, PHOs, MSOs, and other integrated health delivery systems. She draws upon this extensive experience to bring value to physician groups, boards of directors, and ministries of health in more than thirty countries as a teacher, author, speaker, and consultant.

In 2009, she filed for and, after four denials and appeals, successfully prevailed in registering a trademark for a new term of art in the industry for the Globally Integrated Health Delivery System®. The U.S. Patent and Trademark Office accepted her application in August 2010, granting trademark registration to define the term to describe a game-changing organizational structure and function that converges integrated health delivery, key principles of managed care, patient access, care continuity, electronic health information technology for global electronic exchange of health information to improve quality of healthcare, and health travel/medical tourism. The model is now in operation as Mercury Healthcare International, and is positioned to accommodate the healthcare needs of a flatter, more mobile, global society. Todd’s previous consulting projects have resulted in the launch and implementation of more than 150 successful IPAs, PHOs, and MSOs in medical, surgical, behavioral health, complementary and alternative medicine, and ancillary service providers. She has provided expert testimony and supported forensic economists in litigation on failed IPAs, PHOs, and MSOs projects; provided support to private equity investors and market analysts; collaborated with other business consultants and attorneys to help develop private placement memoranda for IPAs, PHOs, and MSOs; provided expert testimony for antitrust litigation brought by "locked-out" IPA and PHO providers; and mediated disputes between payers and provider organizations, and between hospitals and physicians developing PHOs. A frequent speaker in the United States and abroad, and a former member of the McGraw-Hill Healthcare Education Group’s seminar leaders, Todd speaks before numerous state, national, and local organizations; government agencies; hospitals; and provider groups. She is available for in-house training sessions on a variety of topics related to managed healthcare, capitation, provider and network contracting, and integrated delivery system development and management. You may reach her at her office in Denver, Colorado, at (800) 727-4160, or via email at [email protected]