Small doctor groups using IPAs to deliver care management

As physician payment increasingly shifts away from fee for service toward pay for improved quality outcomes, pressure is growing on small, independent doctor groups to keep pace with health-system owned practices.

One way to do that, suggests a study published in August, is for smaller practices to join together and pool resources for chronic disease-management services that can help doctors deliver better care for their patients.

Researchers surveyed a nationwide sample of 1,164 physician practices with fewer than 20 doctors and found that 24% took part in an independent practice association or physician-hospital organization. In these arrangements, individual physician groups maintain separate ownership, but they can join with perhaps 150 to 300 other doctors to negotiate health plan contracts and jointly spend on health information technology and other infrastructure that can improve care. Most of the physician groups surveyed participated in IPAs.

In this study, published in the August issue of Health Affairs, researchers examined the extent to which physician groups composed of mostly internists, cardiologists, endocrinologists and pulmonologists were able to offer care-management services that have been shown to be effective in improving outcomes for patients with chronic diseases. Examples of what researchers called care-management processes include patient registries to track how well patients are doing and nurse care managers to help patients manage their conditions between office visits.

The 24% of practices involved in an IPA or PHO offered an average total of 10.4 care-management processes to patients with asthma, depression, diabetes or heart failure, nearly triple the 3.8 services that the remainder of practices were able to provide.

“Clearly, physicians are under a lot of pressure to be in larger structures,” said Lawrence Casalino, MD, PhD, the study’s lead author and chief of the Division of Outcomes and Effectiveness Research at Weill Cornell Medical College in New York. “That may be larger practices, or many become employed in hospitals. And that could mean the end of small and independent practices.

“The results highlight that the IPAs and PHOs double the number of care-management processes, and that the ones that they particularly offer are the ones that you need resources and economies of scale to get done.”

The findings provide a ray of hope to smaller physician groups, said Stephen M. Shortell, PhD, MPH, co-author of the study and professor of health policy and management at the University of California, Berkeley School of Public Health.

“This is very interesting news, because it means that smaller practices, in fact, might be able to compete in this brave new world if they can get under the umbrella of an IPA of some sort,” he said.

Collective power

The Individual Practice Assn. of Santa Clara County, based in San Mateo, Calif., is one of the IPAs that has figured out how to use the collective purchasing power of its 800 physicians to better manage patient care.

The organization, known as SCCIPA, has purchased software that allows member groups to track patients’ laboratory results, hospital discharge summaries and more. Reminders also pop up on screen when patients are due for mammograms, colonoscopies and other preventive services.

SCCIPA already has three nurse care managers to help and plans to hire two more this year. Patients are stratified by low, medium and high risk for potentially negative outcomes such as hospital admission. Those at high risk get called as often as every other day, said John Kersten Kraft, MD, SCCIPA president and a practicing urologist.

“The first thing we’re able to do is help people who have been hospitalized — when they get out, to get them to their primary care doctors promptly and to their specialty care and to coordinate their medications,” Dr. Kraft said.

“The second thing that has been shown to be helpful is to follow up on a regular basis with, for example, diabetics. To find out what their weight and blood sugars [are], which doctor’s offices don’t have time to do between visits. We can help decide that if someone’s getting into trouble, we can get them into the office before something bad happens.”

The legal rules surrounding IPAs can be tricky, with the Federal Trade Commission ever alert to potential violations of Stark, anti-referral or antitrust laws. Physician groups seeking to join such an arrangement should seek legal advice when doing so, experts said.

Ultimately, patient-level data are needed to determine whether the chronic-disease patients treated by these IPAs are getting care that is on par with the outcomes achieved by larger organizations such as the Geisinger Health System in Danville, Pa., said David B. Nash, MD, dean of the Thomas Jefferson University School of Population Health in Philadelphia.

“The [Geisinger] model is not going to be exportable to the whole country,” he said. “What this article does is it gives us all some hope that these small practices are moving in the right direction.”