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

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Handbook of Concierge Medical Practice Design examines the many considerations physicians must make prior to transitioning their practices into concierge services. Todd, a recognized expert in concierge medicine, branding, consulting, healthcare, marketing, medical tourism, planning, and physician practice administration, explains how to set up a concierge practice. She describes how this new business model affects workflow and outlines financial considerations—including managed care payer relations, the hybrid practice, and predictive modeling—to uncover the hidden factors that affect bottom-line performance.

The book supplies readers with models for creating a business plan and a strategy for transforming a practice into a concierge practice. It concludes by covering the legal aspects of creating a concierge practice. It includes patient acquisition and retention strategies as well as detailed plans for adding additional doctors and physician extenders, such as nurse practitioners and physician assistants. The book provides sample employment contracts and advice on how to select and work with consultants.

It includes chapters on business process re-engineering, workflow management, financial considerations, competitive analysis, developing a business plan, and how to market the new practice.

What Physicians Need to Know About ACOs, Clinical Integration and Alignment

Managed care contracting is a process that frustrates even the best administrators. As explained by Toby C.

Singer, Esq. This concept requires that collective managed care negotiations by the competing providers be reasonably necessary to achieve the clinical integration goals. It is helpful to contrast the facts that caused the FTC to challenge St.

Category: ACO Blog

Critically, they may negotiate separate contracts with health plans if they prefer. The assurances of St. What we need to do is bring together sites of care under a common governance model. That is not to say that employment of 50 percent of more of the primary care physicians in a geographic market by one health system is necessarily going to create antitrust issues going forward.

Until we know more about the St. We will certainly update our readers as the message becomes clearer. Password Forgot Password?

Subscribe to this blog post. Tony Mira. The old fashioned approach of measuring cost of units and volume of units of care does not document individual severity levels of patients and complexity of diagnosis when more than one illness is present. Pendulum Health's information systems capture both inpatient and outpatient data along with ancillary and pharmacy data and compares it to datasets in a given area to compare performance.

Pendulum Health focuses on medical management so local claims payers and health plans often are willing to work with us to better their satisfaction with employer clients.

There is even some residual suspicion today that prevents hospitals from working well with physicians on such things as imaging centers, cardiac labs, orthopedic hospitals and surgery centers. This makes more dollars available, as the patient may be more complicated in their diagnosis.


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It also takes away all medical necessity challenges as the diagnosis fixes a package of services at a predetermined price, again tied to patient need, not the insurance company slide rule. For many physician networks and physician hospital joint ventures the ACO challenge has presented an opportunity to build a competitive strategy to align comprehensive health care services that extend beyond the traditional physician office and institutional setting to include home health, long term care, ancillary care and subspecialties that are used frequently by seniors.

Some clients are signing for all three, some for a single type of ACO configuration, but in all cases physician alignment is key and Pendulum Health has helped clients in building the educational programs to support the rationale for change. Many employers and TPAs are looking for networks that can share some risk and produce better outcomes than the traditional broad panel IPA.

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For many areas of the country where the benchmark is low and the ACO shared savings model does not prove feasible for the Medicare population, the Commercial ACO may be the best starting point to develop a relationship with payers on a direct basis while using the similar metrics of ACO and select HMOs to prove your results of a superior delivery system.

These medical expenses need to be monitored in such a way to get at both large and smaller costs that will vary from ACO to ACO; however, the tools in terms of IT and select staff could be shared expenses between two or three ACOs thereby lowering startup costs and reducing ongoing management costs. A reemergence in the local health plan has come as a result of strong downward pressure on fees and inflation of medical practice expenses. This, combined with larger hospital and health plan consolidation, has created an opening for a local branded health plan offered by and owned by local physicians.

ACO Blog Archives - Page 4 of 10 - Mercury Advisory Group

For both the hospital and physicians these provider based health plans offer a great local alternative to accrue patients and have input into reimbursement. The missing elements have been a technology solution to reward quality and a management solution to get and keep experienced health plan talent. We know employers are rapidly moving away from the discount mentality and toward the need to assure themselves they are purchasing value based quality care.


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This new definition for the hybrid Community Health Plan can offer physicians and hospitals another chance to strongly influence the market, both in terms of Pay for Performance as well as generating a true return on investment for each successful step towards integrating the delivery of care.

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