Individual Practice Association Research Articles

Integrated Medical Groups and Higher-Quality Medical Care

Letters17 July 2007Integrated Medical Groups and Higher-Quality Medical CareP. Dileep Kumar, MDP. Dileep Kumar, MDFrom Port Huron Hospital, Port Huron, MI 48060.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-147-2-200707170-00020 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Mehrotra and colleagues' article (1) on the quality of care provided by integrated medical groups and individual practice associations is flawed because the authors base their conclusions on claims data. It is well known that assuming quality standards from the data that physicians submit for billing purposes is less than perfect. Moreover, the paper implies that solo practitioners and small practices fare poorly in quality measures because they are systematically different. This is not an encouraging comment about the hundreds of practicing primary care physicians, a large majority of them internists.The paper also dwells extensively on ...Reference1. Mehrotra A, Epstein AM, Rosenthal MB. Do integrated medical groups provide higher-quality medical care than individual practice associations? Ann Intern Med. 2006;145:826-33. [PMID: 17146067] LinkGoogle Scholar Author, Article, and Disclosure InformationAuthors: P. Dileep Kumar, MDAffiliations: From Port Huron Hospital, Port Huron, MI 48060.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoDo Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations? Ateev Mehrotra , Arnold M. Epstein , and Meredith B. Rosenthal Integrated Medical Groups and Higher-Quality Medical Care Ateev Mehrotra , Arnold M. Epstein , and Meredith B. Rosenthal Metrics Cited byHIV rapid testing in the framework of an STI prevention project on a cohort of vulnerable Italians and immigrants 17 July 2007Volume 147, Issue 2Page: 147KeywordsComputing systemsConflicts of interestElectronic medical recordsHealth care qualityPrimary care physiciansSystemic diseases ePublished: 17 July 2007 Issue Published: 17 July 2007 Copyright & PermissionsCopyright © 2007 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations?

The association between the organizational structure of physician groups and health care quality has never been evaluated empirically. To examine whether integrated medical groups (IMGs) provide higher-quality primary care than individual practice associations (IPAs). Cross-sectional study. PacifiCare, a large health maintenance organization. Approximately 1.7 million enrollees of PacifiCare cared for by 119 California physician groups between July 1999 and June 2000. The percentage of eligible PacifiCare enrollees who received mammography, Papanicolaou smear screening, chlamydia screening, diabetic eye examination, an asthma controller medication, or a beta-blocker after acute myocardial infarction. Physician groups identified as IMGs, compared with those identified as IPAs, had higher rates of mammography (relative risk, 1.15 [95% CI, 1.01 to 1.33]), Papanicolaou smear screening (relative risk, 2.29 [CI, 1.53 to 3.42]), chlamydia screening (relative risk, 2.17 [CI, 1.04 to 4.55]), and diabetic eye screening (relative risk, 1.55 [CI, 1.28 to 1.88]). Leaders of IMGs were more likely to report using EMRs (37% vs. 2%; P < 0.001) and quality improvement strategies, but these characteristics explained little of the quality differences between IMGs and IPAs. Organizational characteristics, including group type, were reported by physician group leaders and not directly assessed. Patient characteristics that could have accounted for some of the observed differences also were not assessed. Patients cared for in IMGs generally received higher-quality primary care than those cared for in IPAs. Having an EMR and implementation of quality improvement strategies did not explain the differences in quality. These findings suggest that physician group type influences health care quality.

Severe sepsis in managed care: analysis of incidence, one-year mortality, and associated costs of care.

To determine severe sepsis (SS) incidence, hospital mortality, 1-year mortality, and costs associated with care in a sample of enrollees in a nationally representative individual practice association (IPA)-network managed care organization (MCO). This was a retrospective analysis of administrative claims data for commercial (not managed Medicare) members. We identified MCO members hospitalized for SS between July 1995 and December 1998. SS cases were identified by a combination of ICD-9-CM codes for infection and organ dysfunction. Enrollment information, physician, facility, and pharmacy claims were analyzed. Subjects with continuous enrollment were followed for 1 full year of observation. Costs were health plan payments to providers, after subtraction of member cost-share amounts. The incidence rate was 0.91 cases of SS per 1,000 enrollees, increasing with age. The mean age of SS patients was 50 years, and 53% were male. Approximately 63% received surgical intervention. Mortality was 21% during the first hospitalization and 36.1% at 1 year. During follow-up, 47.1% of survivors were rehospitalized. Mean index hospitalization length of stay and costs were 16 days and 26,820 dollars, with 1-year inpatient and outpatient costs totaling 48,996 dollars. Mean outpatient costs per survivor were 8,363 dollars, and mean per-patient-per-month (PPPM) outpatient costs were 906 dollars. Total follow-up costs including rehospitalization were similar for nonsurvivors compared with survivors (7,710 dollars versus 8,522 dollars, P=0.274), but PPPM costs were higher for nonsurvivors (1,760 dollars versus 699 dollars, P<0.001). Incidence, hospital, and 1-year mortality rates were lower in this population compared with literature reports and were associated with a lower average age in this managed care population. Mean SS hospitalization costs were high, and nearly one half of survivors required rehospitalization within 1 year. Study results suggest the need to evaluate SS interventions for improvement in health outcomes and cost outcomes, particularly in postsurgical patients.

Disruption of a Managed Competition Environment by Low-Ball Premium Bids

This paper reviews the movement among multiple health plan options between 1994 and 1998 for Minnesota state employees whose work site was located in the Minneapolis/St. Paul metropolitan area. During this period the employer contribution was based on the lowest family premium bid from a qualified plan in the county of the employee’s work site. In 1995 the largest individual practice association model HMO in the state, Medica, reduced its state premium by 25%, becoming the lowest-priced option. This resulted in massive transfers of enrollees between plans. The point of this study was to estimate the risk changes that resulted from these movements between plan options. We obtained enrollment data by age and gender from Blue Cross Blue Shield of Minnesota (Blue Cross) and applied age/gender risk weight factors derived from actuarial rate tables to the Blue Cross cells. Annual changes in risk weights by 10-20% were common in a number of Blue Cross subpopulations, and in one case, by more than 50%. The Blue Cross POS plan experienced increases in risk and went into a death spiral, while a second Blue Cross plan with a more restrictive provider network started with low risk, but experienced increases in risk when the Medica plan was withdrawn. Similar demographic data were not available from other plans offered by the state and claim costs were confidential, so the results pertain only to Blue Cross risks. The question is raised as to whether managed competition can work without some means of adjusting premium rates to the expected cost level of the enrollees of a particular health plan. All carriers seemed reluctant to guarantee premium rates after the 1994-1998 experience, and the state soon became self-insured.

The feasibility of paper-based Tracking Codes and electronic medical record systems to monitor tobacco-use assessment and intervention in an Individual Practice Association (IPA) Model health maintenance organization (HMO).

Despite evidence of its effectiveness, tobacco cessation is not systematically addressed in routine healthcare settings. Its measurement is part of the problem. A pilot study was designed to develop and implement two different tobacco tracking systems in two independent primary care offices that participated in an IPA Model health maintenance organization in Portland, Oregon. The first clinic, which utilized a paper-based charting system, implemented CPT-like tracking codes to measure and report tobacco-cessation activities, which were eventually included in the managed-care organization's (MCO) claims database. The second clinic implemented an electronic tracking system based on its computerized electronic medical record (EMR) charting system. This paper describes the pilot study, including the processes involved in building provider acceptance for the new tracking systems in these two clinics, the barriers and successes encountered during implementation, and the resources expended by the clinics and by the MCO during the pilot. The findings from the 3-month implementation period were that documentation of tobacco-use status remained stable at 42-45% in the paper-based clinic and increased from 79% to 88% in the EMR clinic. This pilot study demonstrated that Tracking Codes are a feasible preventive-care tracking system in paper-based medical offices. However, high levels of effort and support are needed, and a critical mass of insurers and health plans would need to adopt Tracking Codes before widespread use could be expected. Results of the EMR-based tracking system are also reviewed and discussed.

Redesigning clinical office practices to improve performance levels in an individual practice association model HMO.

Independent Health, a large health maintenance organization in western New York, is participating in a national initiative to redesign the way healthcare is delivered in the clinical office setting. The Idealized Design of Clinical Office Practices (IDCOP) project aims to initiate profound change in the ways physicians deliver care and treatment in the office; the focus is on demonstrating improvements in access to care, patient care, patient and staff satisfaction, and financial performance. Two clinical prototype test sites have successfully implemented an "open access policy," which enables most patients to see their physician on the day an appointment is requested. The two test sites also found improved clinical indicators (for diabetes and coronary heart disease) that positively affected the health of patients; reduced waiting time, enriching the overall experience of the office visit; and improved patient and staff satisfaction with the operational and care delivery modifications. This article describes the findings of the IDCOP initiative at Independent Health.

Reassessing the Plight of Physician Organizations in California: The Uncertain Future for IPAs

With numerous medical groups and individual practice associations (IPAs) in California now reporting operating losses--and many approaching financial insolvency--the question arises why physician organizations are in such a tenuous situation. One line of thinking is that the problem is attributable to the market dominance of the major health plans and their ability to impose actuarially unsound low capitation rates on professional providers. This article describes four other reasons for the current plight of physician organizations: (1) a physician-centric approach to IPA governance, (2) lack of qualified staff within key operating units, (3) management reporting that is insufficient to support utilization analysis and health plan negotiations, and (4) a highly charged political process for determining physician reimbursement. IPA survival will ultimately depend upon whether IPAs are perceived by their physician members and leaders as true business operations or just as another income source.

A Case Study of Point-of-Service Medical Use in a Managed Care Plan

This study examines the extent of point-of-service use in a managed care plan using 1990 and 1991 proprietary claims data (excluding pharmacy claims) from a large, well-established individual practice association with a point-of-service option. Results show that approximately 12 percent of all claims were made by out-of-network providers, representing about 9 percent of the dollar value of all claims. This is about $131 per enrollee per year. While younger enrollees (i.e., 6-24 years of age) use fewer medical resources than do older enrollees, they tend to receive a greater share of their medical services from out-of-network providers. There is little difference between point-of-service use by males and females. Mental illness is the most common diagnosis for out-of-network claims, accounting for about 25 percent of the dollar value of out-of-network claims. Ninety-six percent of the out-of-network claims for this diagnosis category were made by providers with a specialty in psychiatry.

The who, what, and how of managed care.

Since the early 1970s, policy makers and researchers alike have been eagerly watching and evaluating the growth of so-called managed care plans. Many expected prepaid group practice plans (PGPs), then individual practice associations (IPAs), then preferred provider organizations (PPOs), and a host of other insurance arrangements under the managed care label, to result in a more efficient allocation of resources. Others predicted that these changes from the traditional indemnity insurance plans would lead to the denial of needed care and a reduction in the freedom of choice, both for providers and patients. It is a major problem to determine whether either change has taken place because most policy makers and researchers have been less than clear about who or what these plans are supposedly managing, much less how they are managing it. What is this phenomenon called managed care that has elicited so much hope and fear? The confusion exists in part because researchers have used managed care as “the shorthand label for a wide variety of health plans” (Prologue 1999) with “little consensus regarding labels and few accepted criteria for categorization” (Weiner and de Lissovoy 1993: 75). Some might argue that the label is unimportant. However, without knowing what the term managed careis encompassing, how do we know what it is that physicians are presumably revolting against? (see, e.g., Rosenberg 1998; and Ginsburg 1997). Is it “the entire range of utilization control tools that are applied to manage the practices of physicians and others, regardless of the setting in which they practice?” (Weiner and de Lissovoy 1993:

Physician Satisfaction in a Changing Health Care Environment: The Impact of Challenges to Professional Autonomy, Authority, and Dominance

For some time, sociologists have debated whether physicians still retain dominance in the health care world, public faith in their moral and scientific authority, and the autonomy to set work conditions and make clinical decisions. Using ideas derived from this debate, we analyze the impact of changes in the health care environment on physician satisfaction. Our data come from a mailed survey of 510 Arizona physicians. Our results show that background physician attributes did not predict satisfaction, nor did most organizational attributes. However, participation in IPAs (Individual Practice Associations) predicted higher satisfaction, while payment according to a third party payer's fee-for-service schedule predicted lower satisfaction. In addition, physicians were more likely to be satisfied if they wrote the orders that non-physicians had to follow, were paid what they wanted, did not need to subordinate their clinical judgment to that of non-physicians, and believed that their patients had confidence in physicians. Our conclusions discuss both theoretical and policy implications of our findings.

Competition through physician-managed care: the case for capitated multispecialty group practices.

The dominant managed care model in the USA is the individual practice association (IPA), in which physicians in separate practices contract with a health plan. One alternative model, the capitated multispecialty group practice (CMGP), has some distinct advantages: (i) the best randomized trial comparing a health management organization (HMO) with indemnity insurance showed equivalent health outcomes for a prepaid group-practice model HMO, with about a 40% saving in cost, mostly from lower hospital utilization. There is no comparable evidence for IPA-style HMO's; (ii) most managed care plans control costs through 'gatekeeper' primary care physicians or capitated payment. Strong financial disincentives to care, applied to small practices, lead to a significant risk of withholding needed care. Large capitated groups diffuse the risk among hundreds or thousands of physicians; (iii) small practices also lack the financial resources and expertise to develop information systems, continuous quality improvement programs, and other means of improving efficiency. Larger groups can integrate specialty and primary care, laboratory, pharmacy, information technology and other services, to improve quality and cost-effectiveness, while maintaining physician control of the process; (iv) in urban California, HMO enrollment in six large capitated groups increased by 91% from 1990 to 1994. Hospital utilization for these groups was less than half the USA average; (v) because it is self-insured, the CMGP could contract directly with purchasers, eliminating the need for the insurance intermediary. The CGMP offers an ethical, effective alternative that maintains the primacy of the physician in health care: physician-managed care.

Physician Practice Management Companies: What Do They Offer Physicians?

In their article, Lawton R. Burns and James C. Robinson provide a detailed review of a recently prominent group of companies through which healthcare delivery systems are organized. One hopes that the article will be made widely available to physician readers: It should be mandatory reading for all doctors in group practices and individual practice associations (IPAs) and for all who individually contract with managed care companies. The arrival of physician practice management companies (PPMCs) is one of many ways that healthcare in has diversified since the 1970s. It was also an event that some physician groups hoped would help them regain a measure of control over the healthcare process. Burns and Robinson make it clear, however, that any expectations of physician control of healthcare through PPMCs is misplaced. Shortly, this commentary will touch on why such expectations may have existed in the first place and how PPMCs, as expressed in the basic organizational forms characterized by the article, offer little to physicians that they do not already have of their own initiative. Where Did PPMCs Really Come From? One premise of the article is that PPMCs are a new variety of that, by virtue of excluding inpatient capacity, differ from and compete with hospital-led integrated delivery systems (IDSs for the managed care dollar. Looking at these organizations from the point of view of physicians, however, one might include and exclude different organizations in the constellation of PPMCs, some dating considerably further back than those mentioned in the article. If we systematically examine the ways in which physicians' services are organized and extended beyond the local level, PPMCs may just as reasonably include all multispecialty medical practice groups that have geographically diversified. Thus, the fact that Burns and Robinson consider the physician services model the oldest of the PPMC models and date it back to the emergency services companies that arose in the 1970s is correct only if we exclude from the PPMC definition three other models. The Mayo model (the prototype was established in the 1890s as a physician-led group practice and expanded starting in the 1980s), the Henry Ford/ Geisinger model (established as hospital-based, multispecialty group practices in the 1910s and expanded in the 1970s) and the Kaiser/Permanente model (established as a quasi-staff model prepaid healthcare company and geographically diversified in the 1940s) all have roots in the relatively distant past. All provided physicians with the services PPMCs aim to provide, all claimed to fill the customer's needs better than cottage-industry private practice and independent hospitals, all served geographically diverse markets, and all curtailed physician autonomy to a variable extent. It is a little-known fact that the physician equity model, for which Burns and Robinson consider PhyCor the pioneer, was actually part of the business plan of the Federation of Western Clinics as early as 1980. This group of multispecialty clinics of the far west (including, among others, the Virginia Mason Clinic, the Palo Alto Medical Foundation, the Straub Clinic, and the Lovelace Medical Foundation), through their physician CEOs, entered into a venture that went as far as employing full-time staff to plan for the establishment of a physician-controlled equity model super organization of multispecialty clinics. The venture was abandoned when it became evident that despite the CEOs' vision, they were unable to convince the doctors back home to part with any element of local control over contracting, purchasing, capital investment, and earnings distribution. Shortly after the demise of this venture, one of the would-be organizers attempted to resurrect the idea as Physician Corporation of America (Ottensmeyer 1985). Although capitalization could not be arranged at the time, the idea obviously took root. Still, largely as a result of physicians' suspicion of any arrangement that shifts decision making away from the local level, PhyCor spent years using its equity capital to build an infrastructure before it was able to convince any major groups of physicians to sign on. …

Using Claims Data to Measure and Improve the MMR Immunization Rate in an HMO

Health maintenance organizations (HMOs) are increasingly being expected to show evidence of the quality of care provided. One such quality measure is the measles, mumps, and rubella (MMR) immunization rate. This article describes how Blue Choice, an individual practice association (IPA)-model HMO, located in Rochester, New York, with more than 350,000 members, set up a three-phase study to improve immunization compliance rates. The first phase of the study amounted to calculating baseline compliance figures consistent with the American Academy of Pediatrics Immunization protocol using paid claims and membership databases. The second phase was to recalculate the MMR immunization rate based on survey information gathered from primary care physicians and to analyze and address reasons for any observed discrepancies. The third phase was to use Blue Choice Quality Assurance nursing staff to follow up with the remaining noncompliant members and determine the impact of intervention on the MMR immunization rate. Our baseline MMR immunization compliance study yielded a rate of 91.7%, which, as a first check of quality, is quite good in comparison to the nationally reported MMR compliance figures of 79.3%. Phase II analysis demonstrated that by seeking chart information, the overall MMR compliance rate was actually 96.7% Reasons for noncompliance are described, as well as the process used and improvements made, in phase III.

Managed Care Plan Performance Since 1980

To compare the health care utilization, expenditure, quality of care, and satisfaction since 1980 of enrollees in managed care and indemnity plans. Studies selected met the following criteria: data from 1980 forward, private insurance or Medicare enrollees, a comparison group, a reasonable attempt at statistical adjustment for noncomparable managed care and indemnity plan enrollees, and peer-reviewed findings (with two exceptions). Few studies on preferred provider organization plan performance met the selection criteria. Compared with indemnity plans, health maintenance organization plans had somewhat lower hospital admission rates, 1% to 20% shorter hospital length of stay, the same or more physician office visits per enrollee, less use of expensive procedures and tests, greater use of preventive services, mixed results on outcomes, and somewhat lower enrollee satisfaction with services but higher satisfaction with costs. The evidence does not support the hypothesis that prepaid group practice or staff model health maintenance organizations are more effective than individual practice association or network model health maintenance organizations. Although this literature analysis found several clear patterns of results, several factors, including unmeasured selection bias, diverse and rapidly changing health plans and local market conditions, and relatively few research results, suggest that generalizations must be made with caution.

I. Essay: Managed Care: Promise and Concerns

I. Essay: Managed Care: Promise and Concerns

The Employee Health Care Value Survey: round one.

In a groundbreaking arrangement, a consortium of large employers--the Xerox, GTE, and Digital Equipment Corporations--launched the Employee Health Care Value Survey during fall 1993. Completed by 24,306 employees, this survey was used to develop comparable methods for assessing corporate health care benefit strategies. It also enabled fair comparisons of thirty-two health plans across the country on more than sixty criteria. Variation in performance among plans was substantial, with managed care plans--particularly prepaid group practices and individual practice associations (IPAs)--recording the most favorable rankings on disenrollment, overall satisfaction, and other measures of "bottom-line performance." Variation in enrollees' health among plans was more modest, with indemnity enrollees posing a somewhat greater illness burden to their plans than enrollees of other plan types. The employers and evaluated health plans are now using the results for multiple purposes, including quality improvement initiatives, employee-based plan performance reports, employee contribution strategies, and health promotion programs.

Determinants of HMO success: the case of Complete Health.

The health maintenance organization (HMO) industry has experienced a variety of difficulties and criticisms in recent years. Various hybrid models have been proposed to alleviate these problems. This article presents an in-depth case study of factors associated with the success of one such hybrid: an individual practice association (IPA)-model HMO affiliated with an academic health center. The major success factors identified include the plan design/structure, the strategic orientation/practices, and the stakeholder management orientation practices.

Contracts between hospitals and health maintenance organizations

This article describes the contractual relations that are emerging between health maintenance organizations (HMOs) and hospitals. Six HMOs in four large metropolitan areas provided information on 102 hospital contracts. The authors found that the HMOs are becoming more aggressive in placing hospitals in competition with each other for HMO patients. Staff and network HMOs are able to obtain a higher concentration of patients and substantially larger discounts for inpatient services than are individual practice association (IPA) plans in this study.

Patient satisfaction and selected physician behaviors: does the type of practice make a difference?

This study was designed to show what specific physician characteristics lead to patient satisfaction and to compare satisfaction of patients using either prepaid or fee-for-service modes of payment within the same settings. We surveyed 1142 patients in five family practice clinics in rural and suburban areas of the North Central United States. Regression analysis of a seven-item satisfaction scale showed four significant factors that accounted for variance: sensitivity, is on time for appointments, follows up promptly, and provides personalized medical care. No meaningful differences were found between health-maintenance-organization and fee-for-service patients on these satisfactions. This study expands findings from previous research and raises more questions about reliable rating scales for complex physician/patient relations. Our methods can be used to investigate the effects of newer types of prepaid plans (including individual practice associations and preferred provider organizations) on patient satisfaction. The challenge for future investigations is to test and build reliable predictive models showing how physician characteristics, patient satisfaction, and quality of medical care affect each other in these more complex models of practice and reimbursement.

Impact of IPAs on fee-for service medical groups

Individual practice association (IPA) is the newest and most rapidly growing HMO model. Despite potential benefits, IPAs have experienced a variety of difficulties. A case study analysis of community practices in North Carolina revealed satisfactory results as well as concerns.