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E-raamat: Physician Integration & Alignment: IPA, PHO, ACOs, and Beyond

(The Mercury Healthcare Companies, Denver, Colorado, USA)
  • Formaat: 260 pages
  • Ilmumisaeg: 05-Nov-2012
  • Kirjastus: Productivity Press
  • ISBN-13: 9781466588523
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  • Formaat: 260 pages
  • Ilmumisaeg: 05-Nov-2012
  • Kirjastus: Productivity Press
  • ISBN-13: 9781466588523

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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 templatessaving 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.
Acknowledgments xiii
About the Author xv
Introduction xvii
Section I Introduction to Provider Organizations
Chapter 1 The Goals and Objectives of Physician Alignment and Integration: Form Follows Function
3(8)
Chapter 2 Independent Practice Associations (IPAs)
11(20)
Second-Generation IPAs
17(2)
Step 1
18(1)
Step 2
19(1)
Step 3
19(1)
Step 4
19(1)
Financing and Managing the IPA
19(2)
Picking Your Consultants
21(1)
Operations Management for the IPA
21(10)
Administrative Staffing for the IPA
22(1)
Governance Issues for the IPA
22(1)
Start-Up Capital
22(2)
Solvency Standards
24(2)
Steering Committee
25(1)
Bylaws Committee
25(1)
Membership Committee
25(1)
Utilization Management Committee
25(1)
Quality Assurance (QA) Committee
26(1)
Finance Committee
27(1)
Credentialing Committee
27(1)
Other Concerns Relevant to Prequalification for Membership
28(1)
Access Issues
28(35)
Medical Records Review
28(1)
Recertification and Recredentialing
28(1)
Grievance Policies
28(1)
Other Operational Issues
29(2)
Chapter 3 Physician Hospital Organizations (PHOs)
31(14)
PHO Revenue Allocation
32(1)
PHO Direct Contracting
32(1)
Negotiation and Projection Hindrances
33(1)
Differences in Administrative Style among Members
33(2)
Managed Care Contracting with Payors
35(1)
Governance Issues: Control
35(1)
Medicare Anti-Kickback and Practice Acquisitions
36(9)
Chapter 4 Accountable Care Organizations (ACOs)
45(10)
Chapter 5 Management Services Organizations (MSOs)
55(8)
Three Basic Elements of MSOs
55(8)
Section II Integrated Health Delivery System Development
Chapter 6 Corporate Form: Myriad Choices
63(10)
General Partnerships
63(1)
Disadvantages of General Partnerships
63(1)
Limited Partnerships
64(2)
Advantages of Limited Partnerships
64(1)
Disadvantages of Limited Partnerships
65(1)
Corporations
66(2)
Advantages of Corporations
66(2)
Disadvantages of Corporations
68(1)
The Subchapter S Corporation
68(2)
Disadvantages of S Corporations
69(1)
Double-Taxation Considerations
70(1)
The Limited Liability Corporation (LLC)
70(3)
Chapter 7 The Steering Committee Gets Busy: Step-by-Step Instructions for What to Do and How to Do It
73(10)
Steering Committee Task List
73(6)
Background/Understanding of Task
73(2)
Develop a Statement of the Committee's Purpose
73(1)
Approach
74(1)
Development of the Shared Vision
75(1)
Organizational Development of the IPA
75(2)
Organizational Development of the MSO Required of the Steering Committee
77(1)
Market Focus
78(1)
Development of a Business Plan
78(1)
Organizing the Steering Committee
79(4)
Multi-Specialty IPA or PHO
79(1)
Single-Specialty IPA or PHO
80(1)
Management Services Organization (MSO)
81(1)
Other Concerns of the Steering Committee
81(2)
Chapter 8 Guidance for the Utilization Management and Quality Improvement Steering Committees
83(8)
First Things First
84(7)
Utilization Management Program Outline
84(1)
Quality Improvement and Assurance Program
85(1)
Activities to Study and Frequency of Each Study
86(1)
Frequently Asked Questions by the Health Plans (Don't Be Caught Without An Answer!)
86(1)
Documentation Quality
87(1)
Adverse Outcome Review
88(3)
Chapter 9 Network Financial Management: The Intersection of Finance, Utilization Management and Capitated Risk Management
91(6)
Finance Reports
92(1)
Utilization Management Reports
92(3)
Additional Monitoring Reports
95(2)
Chapter 10 Provider Organization Credentialing and Privileging
97(10)
Typical Managed-Care Provider Organization Representations and Warranties
97(2)
Provider Expectations
99(1)
Practitioner Requirements
99(1)
Non-Physician and Provider Requirements
100(1)
Credentialing Process
101(3)
Delegated Credentialing
104(1)
Acknowledgment
105(2)
Chapter 11 Credentialing Committee's Assignment: What to Do and How to Do It
107(10)
Due Diligence in Credentialing
108(3)
Vicarious Liability
109(1)
Master and Servant Liability
109(1)
Ostensible Agency
110(1)
Structuring a Good Credentialing Policy
111(1)
Provider Application for Credentialing
112(5)
General Information
112(1)
Licensing/Certifications/Registration Numbers
113(1)
Hospital Privileges
113(1)
Professional Liability Coverage (at the time this application is completed)
114(1)
Disciplinary Actions
114(1)
Professional References
114(1)
Office Information
114(3)
Chapter 12 Antitrust Compliance Task Force: Understanding Antitrust Concerns for Provider Networks
117(20)
What Are the Antitrust Laws'
118(1)
Terms Used in the Guidelines
118(3)
Federal Guidelines of Antitrust Enforcement Policy in Healthcare
121(4)
Statement 4: Providers' Collective Provision of Non-Fee-Related Information to Purchasers of Healthcare Services
122(1)
Statement 5: Providers' Collective Provision of Fee-Related Information to Purchasers of Healthcare Services
122(1)
Statement 6: Provider Participation in Exchanges of Price and Cost Information
123(1)
Statement 7: Joint Purchasing Arrangements among Healthcare Providers
124(1)
Statement 8: Physician Network Joint Ventures
125(1)
Use of the Messenger Model to Negotiate an Agreement with a Payor
125(1)
Characteristics of the Arrangement
125(1)
Legality of the Arrangement
126(1)
Variations on the Messenger Model
126(1)
Non-Integrated Network that Presents and Discusses Non-Fee Related Information and Uses the Messenger Model for Financial Arrangements
127(3)
Case Scenario
127(3)
Legality
129(1)
Variation on the Arrangement
129(1)
Legality
129(1)
Variation on the Arrangement
129(1)
Legality
129(1)
Qualified Managed Care Plans (QMCPs)
130(7)
How the QMCP Concept Came About
130(2)
Substantial Financial Risk Must Be Shared
132(1)
Agency Analysis of Physician Network Joint Ventures that Fall Outside These Antitrust "Safety Zones"
132(1)
Statement 9: Multi-Provider Networks
133(1)
Shared Substantial Financial Risk
133(1)
No Sharing of Financial Risk
134(1)
Rule of Reason Analysis
134(1)
Selective Contracting
134(1)
Messenger Models
135(1)
Useful Addresses and Telephone Numbers
135(2)
Chapter 13 Business Plan Development
137(12)
Model Business Plan
139(7)
Executive Summary
139(4)
Company Direction
139(1)
Company Overview
140(1)
Objectives
140(1)
Capital Requirements
140(1)
Management Team
140(1)
Service Strategy
141(1)
Market Analysis
141(1)
Customer Profile
141(1)
Competition
141(1)
Risk
142(1)
Marketing Plan
142(1)
Marketing Strategy
142(1)
Advertising and Promotion
142(1)
Public Relations
143(1)
Financial Plan
143(3)
Conclusion
143(1)
Financial Plan
143(1)
Assumptions
143(1)
Gross Profit Analysis
144(1)
Budget—Income Statements
144(1)
Balance Sheets
144(1)
Cash Flows Statements
145(1)
Break-Even Analysis
145(1)
Capital Requirements
145(1)
Use of Funds
145(1)
Exit/Payback Strategy
145(1)
Conclusion
146(1)
Keeping Your Infant Business Competitive: Nondisclosure Agreements
146(25)
Sample Nondisclosure Agreement
146(3)
Chapter 14 Guidance for the IT Committee
149(10)
Section III Business Development: Contracting and Marketing
Chapter 15 Contracting with Payer Organizations
159(12)
Chapter 16 Contracting for Capitation and Bundled Service Arrangements
171(12)
Capitation
171(2)
Capitation Demographics Analysis
171(1)
Services
172(1)
Dealing with Unpredictable and Unmanageable Risk Reinsurance
173(1)
Dividing the Pie
173(2)
Fee Schedules
175(1)
Case Rates
176(11)
The Moral of the Story
180(3)
Chapter 17 Understanding Capitation Performance Guarantees
183(4)
Chapter 18 Considerations for Reinsurance Purchases for the Integrated Health Delivery System
187(8)
Covering the Remainder
188(1)
Policy Key Features
188(5)
What to Consider when Buying Capitated Stop Loss/Reinsurance from a Private Insurer
190(2)
What to Consider when Buying Coverage from an Insurance Company
192(1)
Dealing with Managing General Underwriters (MGUs)
193(2)
What to Consider when Purchasing from a Managing General Underwriter
193(2)
Chapter 19 Opportunities in Delegated Utilization Management and Claims Management for the MSO
195(4)
Claims Payment Responsibilities (Delegated Claims Payment)
195(1)
Utilization Management (Delegation of Utilization Management)
196(3)
Chapter 20 Beyond Traditional HMO and PPO Contracts: Direct Contracting with Employer-Sponsored Health Benefit ERISA Plans
199(12)
More ERISA Plans than NCQA-Accredited HMOs and PPOs
200(4)
Demystifying Covered and Non-Covered Services
200(4)
Wrap SPD Document Requirements
204
Section IV Appendices
Appendix A: Volunteer Committee Survey Form
211(2)
Appendix B: Sample LLC Document Set
213(6)
Appendix C: How to Hire the Right Consultants
219(12)
Index 231
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. Todds 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 Groups 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 maria@mariatodd.com.