HOW NETWORKS IMPACT PRIMARY CARE PHYSICIANS

Consider in Forming Networks/(Same approach can be applied to Joining a Group Practice):

  • Structure of Relationship & Earnings
  • Specialists relationship to PCPs
  • Interaction/ Cooperation between members of group
  • Range of services/ Competency level of peers (concern: malpractice)
  • Geographic range for coverage/ How large of practice/ Prior experience requirements
  • Other facilities and providers necessary for meeting patient needs/ Role of PCP/ Acceptance by group – key for system to work effectively
  • Core business expertise: Financial oversight/ Administrative management/ Continuous Quality Improvement (“CQI”) program/ Marketing plans
  • Sufficient capital to support operations and underwrite short-term losses: Run central business office, employ personnel with business expertise, rent or buy office space, supplies, office equipment, information systems, and offset possible risks

Typically, some issues PCP’s must address as they form these networks or consider joining them include the following:

  1. Who will employ physicians (or how is the relationship structured) and what will earnings be, i.e. will the physicians work for group, hospital or independent network.
  2. How specialists will relate to PCP.
  3. How do the individual PCP’s interact with each other and how cooperative are they as a group.
  4. What is the range of services they, as a group, can provide and is everyone providing services competent so as not to subject others to malpractice allegations.
  5. What is their geographic range for coverage, and how large of a practice do they want, and do they require prior managed care experience in order for providers to be part of the group.
  6. Which are the other facilities and providers necessary for meeting patient needs, such as specialists, subspecialists, hospitals, adjunct providers such as home health care groups and nursing homes. What is the role of the PCP as clinical manager and director of patient care and is this role accepted by the other affiliated providers as this is key for the system to work effectively.
  7. What is the core business expertise – including financial oversight and administrative management. Do they know how to implement a continuous quality improvement (“CQI”) program and execute marketing plans. (CQI) should include rigorous credentialing standards, regular review of practice patterns, study of clinical outcomes, routine utilization review and case management. Key administrative priorities include efficient claims processing system, management information systems that are linked to other participatory providers, contracting expertise, plan for developing and maintaining provider relations.
  8. Is there sufficient capital of the primary care practice network to support operations and underwrite short-term losses. For example, is there sufficient capital to run a central business office, employ personnel with business expertise, rent or buy office space, supplies, office equipment, information systems, and offset possible risks.

A continuous quality improvement (CQI) program for Primary Care Physicians (PCPs) may include:

  • Rigorous credentialing standards
  • Regular review of practice patterns
  • Study of clinical outcomes
  • Routine utilization review
  • Case management

Primary care networks that combine medical expertise with business ability have been called “group practice without walls.” Primary care networks may be broadly defined as a geographically dispersed group with primary care as its main goal. These networks contract with providers to define the conditions under which they will operate and the provisions for reimbursement. The role of the PCP as clinical manager and director of patient care must be understood and accepted by the other providers (such as specialists, subspecialists, hospitals) for the system to work effectively.  Some PCP groups may follow the following practices to adjust to the managed care environment:

  • Forming alliances with other primary care physicians
  • Initiating networks of care with local hospitals
  • Helping define their plan’s clinical guidelines
  • Helping their plan develop a fair method of utilization review
  • Asking for a fair withhold percentage
  • Agreeing to submit to statistical profiling instead of case-by-case review
  • Allowing retrospective review for information only, not to deny claims
  • Encouraging their plan to improve its coverage of preventive medicine
  • Asking that the plan include their preferred sub-specialists on their panel

Key administrative priorities include efficient claims processing system, management information systems linked to other participatory providers, contracting expertise, plan for developing and maintaining provider relations.

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