Todd Physician Integration & Alignment

IPA, PHO, ACOs, and Beyond
Erscheinungsjahr 2013
ISBN: 978-1-4665-8852-3
Verlag: Taylor & Francis
Format: EPUB
Kopierschutz: 0 - No protection

E-Book, Englisch, 260 Seiten

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.

Zielgruppe

Senior managers involved in business development and strategy for hospitals and health systems, physician executives and leaders in hospitals and health systems, physicians in executive MBA programs.

Autoren/Hrsg.

Todd, Maria K.

Fachgebiete

• Mathematik | Informatik EDV | Informatik Betriebssysteme
• Wirtschaftswissenschaften Betriebswirtschaft Management

Inhaltsverzeichnis

INTRODUCTION TO PROVIDER ORGANIZATIONS

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

INTEGRATED HEALTH DELIVERY SYSTEM DEVELOPMENT

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
Approach
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
Corporations
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
Acknowledgment

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
Legality
Variation on the Arrangement
Legality
Variation on the Arrangement
Legality
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
Objectives
Capital Requirements
Management Team
Service Strategy
Market Analysis
Customer Profile
Competition
Risk
Marketing Plan
Marketing Strategy
Advertising and Promotion
Public Relations
Financial Plan
Conclusion
Financial Plan
Assumptions
Gross Profit Analysis
Budget—Income Statements
Balance Sheets
Cash Flows Statements
Break-Even Analysis
Capital Requirements
Use of Funds
Exit/Payback Strategy
Conclusion
Keeping Your Infant Business Competitive: Non-Disclosure Agreements
Sample Non-Disclosure Agreement

Guidance for the IT Committee

BUSINESS DEVELOPMENT: CONTRACTING AND MARKETING

Contracting with Payer Organizations

Contracting for Capitation and Bundled ServiceArrangements
Capitation
Capitation Demographics Analysis
Services
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

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

Über Autor(innen)

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 [phone], or via email at [e-mail].