Physician Networks
Systems Framework for Understanding Managed Care
EMPLOYERS
Plan Choices,
Employee
Premiums,
Information
Marketing,
Product
Development
Job preferences,
Wage and Benefit
Preferences
Select Products,
Join Plan
MCO
Member
services
Enrollees
Marketing,
Advertising,
Information,
Reputation
Taxes,
Votes
Employee
Plans,
Medicare,
Medicaid,
Information
Contract for
Product, Risk,
Premiums,
Benefits
Regulate Allowed
Products, Behavior
Relationships
GOVERNMENT
Adapted from Gold , Medical Care Research and Review 52(3): 307-341, Figure 1.
Utilization
management
CARE
Payment,
Risk, Practice
Guidelines,
Profiling
Provider
Network
CONSUMERS
Contract for Product,
Premiums/Benefits,
Risk
Customer
Volume
Type of Plan,
Philosophy and
Procedures for
Selection/Retention
PHYSICIANS
Specialty, Style of
Care, Discounts,
Form of Organization
Discounts,
Specialized
Services
Treatment
Facilities
and
Prescribed
Services
HOSPITALS &
OTHER SUPPLIERS
Admissions,
Prescriptions,
Referrals
Plan for Today
• HMO models
– Distinguished by relationship between
physicians and plan
• Creating physician network
– How many of what kind of physicians?
– Recruiting process
• Network management
HMO models
• Distinguished by relationship between plan
and physicians
–
–
–
–
–
Staff model (Group Health of Puget Sound)
Group model (original Kaiser, Geisinger)
Network model (Health Insurance Plan of NY)
Individual practice association (IPA, MD-IPA))
Direct contracting (Aetna-US Health Care)
“Closed panel” HMO models
Staff
model
Physicians are (usually salaried)
employees of plan
Group
model
Physicians are (usually salaried)
employees of a single, large group
that contracts exclusively with plan
Network Plan contracts with multiple
physician groups that employ
model
physicians
“Open Panel” HMO models
IPA
Physicians retain independent
practices. Join association that
contracts with plan
Physicians retain independent
Direct
Contracting practices. Contract individually
with plan.
Competitive Advantages
Closed panel
Open panel
Competitive Disadvantages
Closed panel
Open panel
Percent of HMO Enrollees By
Model Type
60%
52%
50%
43%
40%
30%
20%
25%
16%
14%
10%
0%
Staff
Group
Network
IPA
Mixed
Creating Physician Network
• Closed panel versus open panel
• How many of what kinds of physicians?
• Open-panel recruiting process
Closed Panel versus Open Panel
• Closed panel hires physicians
– May contract for some specialty care
• Open panel contracts with physicians
How Many of What Kind of
Physicians?
• Member-to-physician ratios
• Geographic access
Member-to-physician ratios
• Fulltime staffing ratios--1 physician for every
– 2,000 to 5,000 members
– 20,000 members
– 35,000 members
– 150,000 members
Primary care
General surgery
Cardiology
Neurosurgery
• Open-panel ratios are less than fulltime
– For example, 200-500 members per Primary Care
Physician (PCP)
Geographic Access
• One PCP within 15 miles or 30 minutes of
every member
• 2 PCPs within 8-mile radius in urban areas
• 2 PCPs within 20-mile radius in rural areas
Recruiting Process
• Assess needs
• Identify candidates
– Hospital affiliations
• Telephone or mail contact by recruiter (part
of provider services unit)
• Application (individual physician)
or contract negotiation (physician group)
Credentialing
•
•
•
•
Training
Specialty board eligibility or certification
State medical licensure
Drug Enforcement Agency (DEA) number
– Prescription dispensing license
• Hospital privileges
• Malpractice insurance
Credentialing (cont.)
• Malpractice history
• National Practitioner Data Bank check
– Hospitals, plans, malpractice carriers, state
licensure boards required to report
• Settled or lost malpractice suits
• Sanctions or restrictions against practice privileges
• Number and location of offices
Recruiting (cont.)
• Office evaluation
• Medical record review
• Orientation
Network Management
• Provider relations
– Re-credentialing
– Addressing problems encountered by providers
and office staff
– Educating providers and office staff
– Implementing network changes
• Clinical management