Physician Networks

1. Physician Networks

2. Systems Framework for Understanding Managed Care EMPLOYERS Plan Choices, Employee Premiums, Information Contract for Product, Premiums/Benefits, Risk Marketing, Product Development Job preferences, Wage and Benefit Preferences Payment, Risk, Practice Guidelines, Profiling MCO Type of Plan, Philosophy and Procedures for Selection/Retention Member services Utilization management Select Products, Join Plan CARE Provider Network PHYSICIANS CONSUMERS Enrollees Marketing, Advertising, Information, Reputation Specialty, Style of Care, Discounts, Form of Organization Taxes, Votes Contract for Product, Risk, Premiums, Benefits Discounts, Specialized Services Employee Plans, Medicare, Medicaid, Information Treatment Facilities and Prescribed Services Customer Volume Admissions, Prescriptions, Referrals Regulate Allowed Products, Behavior Relationships GOVERNMENT HOSPITALS & OTHER SUPPLIERS Adapted from Gold , Medical Care Research and Review52(3): 307-341, Figure 1.

3. 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

4. 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)

5. “Closed panel” HMO models

6. “Open Panel” HMO models

7. Closed panel Open panel Competitive Advantages

8. Closed panel Open panel Competitive Disadvantages

9. Percent of HMO Enrollees By Model Type

10. Creating Physician Network • Closed panel versus open panel • How many of what kinds of physicians? • Open-panel recruiting process

11. Closed Panel versus Open Panel • Closed panel hires physicians • May contract for some specialty care • Open panel contracts with physicians

12. How Many of What Kind of Physicians? • Member-to-physician ratios • Geographic access

13. Member-to-physician ratios • Fulltime staffing ratios--1 physician for every • 2,000 to 5,000 members Primary care • 20,000 members General surgery • 35,000 members Cardiology • 150,000 members Neurosurgery • Open-panel ratios are less than fulltime • For example, 200-500 members per Primary Care Physician (PCP)

14. 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

15. 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)

16. Credentialing • Training • Specialty board eligibility or certification • State medical licensure • Drug Enforcement Agency (DEA) number • Prescription dispensing license • Hospital privileges • Malpractice insurance

17. 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

18. Recruiting (cont.) • Office evaluation • Medical record review • Orientation

19. Network Management • Provider relations • Re-credentialing • Addressing problems encountered by providers and office staff • Educating providers and office staff • Implementing network changes • Clinical management