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

Physician Integration & Alignment

IPA, PHO, ACOs, and Beyond, 1st Edition

By Maria K. Todd

Productivity Press

260 pages | 12 B/W Illus.

Purchasing Options:$ = USD
Hardback: 9781439813089
pub: 2012-11-05
eBook (VitalSource) : 9780429244896
pub: 2012-11-05
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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

About the Author

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]

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Management Science
BUSINESS & ECONOMICS / Quality Control
COMPUTERS / Operating Systems / General
MATHEMATICS / Combinatorics