Come Together: In environment of increasing consolidation, nephrologist founds independent practice association

Hogan, Michelle

doi: 10.1097/

As the United States' evolving health care delivery system continues to drive collaboration and consolidation in medicine, providers are looking within to see what degree of cooperation best suits their needs. For Long Island, NY-based nephrologist Simon Prince, MD, an independent practice association (IPA) was the answer.

“Here there's a dominant player—a big health system—but this is a nationwide phenomenon where a large amount of private-practice physicians are being acquired in a manner by hospitals,” Dr. Prince said in a phone interview.

Dr. Prince is President of North Shore Nephrology in Manhasset, NY; Medical Director of Queens–Long Island Renal Institute in New Hyde Park, NY; and President & CEO of Beacon IPA, which he founded in the summer of 2010.

“Big groups are forming, independent private practice is really being squeezed, and it's becoming more challenging to survive, for a variety of reasons,” he said. “I thought that this would be a good vehicle to give another choice to independent practitioners who were looking for a way to come together but still maintain some independence and autonomy.”

The IPA model is one way for practices to join forces, agreed Franklin W. Maddux, MD, Senior Vice President and Chief Medical Information Officer for Fresenius Medical Care.

“It doesn't mean that the practice loses its autonomy completely, but it gains a larger stage and setting for understanding regulatory items and items that are of benefit to the individual practice by learning from their peers,” he said in a phone interview.

“I don't know that it will be the dominant model everywhere, but I think it is one way in which smaller practices that wish to remain independent can gain some of the advantages of a larger organization and some of the thought power that comes from having more people involved.”

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Achieving Clinical Integration

The level of integration in an IPA is somewhat looser compared with other options for collaboration.

“It's a little easier in and out,” Dr. Prince said. “You don't have to rip down your corporation; you don't have to jump through hoops to get involved.”

Beacon IPA currently includes about 200 physicians, approximately 100 of whom are primary care physicians and 10 of whom are nephrologists. Other specialists include cardiologists, pulmonologists, infectious disease physicians, dermatologists, and surgeons, including vascular surgeons.

Beacon's goal is to comprise more than 50% primary care physicians. The IPA is spreading geographically from its base on the North Shore of Long Island to Queens County in New York and to the South Shore and eastern reaches of Long Island.

“We can talk to the payers on a different level when we have a couple hundred docs versus a few docs in a single practice,” Dr. Prince said. “It allows us to affect change because we'll have different committees dealing with different quality initiatives, clinically integrate in a way in which we can get data that has significant breadth, and then look at that data, improve upon it, and use it to show the quality.”

This emphasis on quality is shown in part by Beacon raising the bar on its standards for new members, he noted.

“We need to fill holes because we want all of our specialties covered, but we're looking for different groups geographically, how they work, look at malpractice histories, who's referring them and where they're coming from, and then we investigate,” Dr. Prince said.

The focus on a certain level of clinical integration is another important factor, he noted.

“As we move toward clinical integration, that is what's going to make us a little different—a little more tightly knit and a little better—but clinical integration is very difficult to achieve.

“Our members need to be on an EMR [electronic medical record] within six to 12 months of joining us or they will be out of the IPA. All of our members need to be on an EMR that qualifies for meaningful use so we can all talk and share data and integrate, and that's the challenge of the organization now.” Members can use the EMR system of their choice.

For Beacon, clinical integration is also a step toward a potential goal.

“We want to use a clinically integrated IPA as a vehicle to become an accountable care organization [ACO], perhaps,” Dr. Prince said. “That's a very hot topic now—what is an ACO and where do ACOs fit—and we're waiting for more light on that.

“There's a ton of speculation, but we don't want to be caught flat-footed, so we're putting infrastructure in place.”

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Not a Stand-Alone Solution

Independent practice associations have value not as stand-alone solutions but as part of a larger scale accountable care organization, said Theodore I. Steinman, MD, Clinical Professor of Medicine at Harvard Medical School and Senior Physician at Beth Israel Deaconess Medical Center, in a phone interview.

“The IPA can represent the really truly integrated model of care, short of maybe all the financial issues that are necessary for that, and those you can delegate to the ACO.

“IPA member physicians can set up patient chart-sharing; they can set up a model for IT—how do you transmit records back and forth with patient protection—that will decrease costs by preventing duplication, eliminating unnecessary testing procedures, and reducing medical error. I think the electronic health record, electronic medical record, will facilitate communication between doctors and obviously between institutions.

“If you're coming in when ACOs are being formed, you can be a player at the table. You're bringing size, speaking with clout, etc.”

Dr. Maddux also noted the potential for an independent practice association to participate in an ACO when he commented on the benefits and costs of the IPA approach.

“I think the benefits are access to the intellect of the group, access to those items needed to run your nephrology practice that some degree of scale might create either a functional or financial benefit, and the ability to look at participation in some of these innovative delivery models in a less risky way for the practice,” he said.

“An example of that would be a practice under an IPA group might well qualify to participate in what we think an accountable care organization may look like, and that participation as an IPA or as a group that affiliates with some other larger organization has the ability then to gain the benefit of resources for analysis of patient populations that they might not individually and independently be able to afford to embed in their practice, and those population dynamics and analytics are going to be some of the key factors, I believe, that create opportunities for success under the accountable care model, shared savings models.

“Some of the costs to these things are money, time, effort, and control because you give up a little bit of your independence whenever you affiliate with others in any way, whether it's a high-and-tight kind of affiliation or whether it's a loose affiliation, so as a practice you have to be committed to working with others and listening to points of view other than your own.”

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Collaboration Is Unavoidable

While the options for partnering with other medical providers come in all different shapes and sizes, those interviewed for this article agreed that in this day and age, some level of collaboration is unavoidable.

“The days of hanging out a sign and being a solo practitioner have ended,” wrote Gary Cellini, PharmD, MBA, Vice President of Strategic Planning for Satellite Healthcare, in an e-mail.

“A specialist such as a nephrologist has to either be part of a large single-specialty group practice that dominates the market, join an IPA (or several IPAs), be part of an IPA (or several IPAs) that is/are subcontracted with large employee multispecialty groups, or become an employed physician in a large employee multispecialty group—e.g., Palo Alto Medical Foundation, Kaiser [Permanente], Cleveland Clinic, etc. I see a lot of consolidation in the near future.”

In deciding what form of collaboration to pursue, a practice should look within.

“I think ultimately one of the things this requires is that the practice ask itself very fundamental questions about what kind of practice they see themselves having over time,” Dr. Maddux said. “Is it one that creates a culture that is strictly based on independence and autonomy, or is it one that moves more toward a collaborative model and looking at shared best practices that might emanate from your own practice but might actually be proposed and promoted from a neighboring practice that's part of the collaboration.

“I think the practice and the practitioners in that practice have to become comfortable with the culture of collaboration and comfortable with whether they can be in that environment and feel that that leads to good practice of medicine, a good lifestyle, and a good return on what they're putting into it.

“I would simply say that practices need to look inside themselves very carefully and say, what is it we want to be; how do we want to do that, and honestly look at all of the options for who's best to do that with because it may be another practice or group of practices; it may be the relationship with your dialysis provider; it may be geographic in your local community.

“It won't be the same for every practice. That will depend on how they're set up and what they see of themselves in the future.” •

© 2011 Lippincott Williams & Wilkins, Inc.