MedSouth
GRIPA
Advocate Health Care
Brown and Toland

MedSouth

Article Excerpt
by Amelia Williams Koch, Alexander M. McIntyre, Jr.
June 26, 2007

In early 2002 the FTC issued its advisory opinion to MedSouth, Inc., a physician network joint venture in Denver, Colorado, concluding that MedSouth's clinical integration efforts were sufficient to justify collective pricing. This particular opinion was especially important, as it was the first to explore clinical integration in any detail, and the first approval of physician joint pricing based upon clinical, as opposed to financial, integration. In its Opinion, however, the FTC warned that it would monitor the future of MedSouth, worried that unduly anticompetitive results would outweigh the proposed efficiencies.

On June 18, 2007, the FTC released its long anticipated follow-up to the 2002 MedSouth advisory opinion (the Follow-up). It seems the MedSouth network got it right, as the FTC "see[s] no reason at this time to rescind or modify" its earlier conclusions approving MedSouth's operations.

Visit this link for more information about the FTC follow-up on MedSouth.

GRIPA

FTC Staff Advises Rochester Physician Organization That It Will Not Recommend Antitrust Challenge to Proposal to Provide Member Physicians' Services Through "Clinical Integration" Program

Program Would Involve Joint Negotiation of Contracts and Prices With Health Plans
Staff of the Federal Trade Commission have advised the Greater Rochester Independent Practice Association, Inc. (GRIPA), a multi-specialty physician practice association that includes competing primary care and specialist physicians that practice in the three-county greater Rochester, New York, area, that it has no present intention to recommend a challenge to the organization's proposed operation as a non-exclusive physician network joint venture. GRIPA requested a staff advisory opinion concerning its proposal to integrate and coordinate the provision of medical services to patients by about 575 physicians in 41 medical specialties through a program of "clinical-improvement services" through which the physicians would work together to improve quality and control costs.

GRIPA's proposed program seeks to coordinate the care provided to patients by its physicians. Physicians generally will be required to refer patients to physicians within the network, in order to better assure that care is subject to GRIPA's treatment standards at all times, and to better monitor treatment and outcomes. The program includes several components intended to assure that its physicians use "best practices" and "evidence-based" medicine in treating patients. Patients' treatment and the physicians' individual and aggregate performance will be carefully monitored and measured against benchmarks for improved patient outcomes, and reduced costs and resource use. Disease management and case management programs will help patients comply with necessary self-care and behavioral recommendations from their doctors.

The program will have an extensive Web-based electronic clinical information system allowing physicians to share information regarding their common patients, access patient information from hospitals and ancillary providers throughout the community, and order prescriptions and lab tests. In addition to agreeing to adhere to all of GRIPA's practice requirements under the program, the physicians, who have a history of working together under GRIPA's HMO risk contracts, will invest significant time and effort in collaboratively developing and overseeing implementation of the program's practice guidelines and protocols. They also will participate in monitoring and evaluating their peers' performance and addressing any performance deficiencies, including disciplining and, if necessary, even expelling from the organization physicians who continue to fail to comply with the program's requirements and adhere to its standards.

GRIPA will contract jointly for the sale of its participating physicians' services to health plans on a fee-for-service basis. GRIPA believes that joint contracting with payers is necessary in order to assure that all its physicians participate in the program for all patients and under all contracts, and thereby better achieve its quality and efficiency goals. Having all network physicians participate in all contracts also will permit GRIPA to obtain more complete information in monitoring patients' treatment, outcomes, and quality of care, and for evaluating physicians' adherence to program standards and the achievement of the program's cost savings targets and other efficiency measures.

GRIPA will operate as a non-exclusive network, which means that its individual physician members will be available to negotiate and contract separately with health plans and other customers not wishing to purchase the network services. While the staff letter could not prospectively determine what, in fact, the competitive effects of the proposed program's operation would be, and raised some concerns about the percentages of GRIPA physicians in certain specialties in some areas, it nevertheless concluded that GRIPA appeared unlikely to be able to exercise market power or have anticompetitive effects in the market for provision of physician services in the greater Rochester area for several reasons. In addition to its commitment to operate non-exclusively, and apparent past record of doing so, other physician networks appeared to be available in the area, and health plans operating in the area appeared likely to be able to maintain adequate physician networks for their programs.

The staff opinion letter, dated September 17, 2007, was signed by Markus H. Meier, Assistant Director of the Health Care Services and Products Division of the Federal Trade Commission's Bureau of Competition. It concluded that the proposed program appeared to "involve substantial integration by its physician participants that has the potential to result in the achievement of significant efficiencies that may benefit consumers." The letter also concluded that joint contracting by GRIPA appeared to be subordinate to the program's primary purpose of interdependently improving the quality and efficiency of the member physicians' services, and appeared to be "subordinate to, reasonably related to, and may be reasonably necessary for, or to further, GRIPA's ability to achieve the potential efficiencies" from the program. The program's joint contracting therefore would be subject to analysis under the antitrust rule of reason, rather than being considered per se illegal price fixing.

Because of the program's procompetitive potential, the ancillarity of the joint contracting to furthering achievement of its potential efficiencies, and the indications that GRIPA would be unlikely to be able to exercise market power, staff concluded that they would not recommend that the Commission challenge the program "unless it became apparent that GRIPA in fact was able to exercise market power or otherwise have an anticompetitive effect in a relevant market."

Visit this link for more information about GRIPA and to read the FTC advisory opinion.

Advocate Health Care

Oak Brook-based Advocate Health Care, the largest health care provider in Illinois, is ranked among the nation's top health care systems. A faith-based, non-profit system, Advocate is related to both the Evangelical Lutheran Church in America and the United Church of Christ. Advocate's 200-plus sites of care in metropolitan Chicago include eight acute care hospitals and two children's hospitals, a home health care company and four of Chicago's largest medical groups. Through its academic and teaching affiliations, Advocate trains more resident physicians than does any non-university teaching hospital in Illinois. For more information about Advocate Health Care, please visit www.advocatehealth.com.

Advocate Physician Partners is the care management and managed care contracting joint venture between Advocate Health Care and select physicians on the medical staffs of Advocate hospitals. With a physician network that includes more than 900 primary care physicians and 2,000 specialists, Advocate Physician Partners is focused on improving health care quality and outcomes - while reducing the overall cost of care - in both the inpatient and ambulatory settings. Advocate Physician Partners' award-winning clinically integrated approach to patient care utilizes best practices in evidence-based medicine, advanced technology and quality improvement techniques.

By Amy Lynn Sorrel, AMNews staff. Feb. 5, 2007.
In what is believed to be the first decision of its kind, the Federal Trade Commission has given the go-ahead for a physician organization investigated for price-fixing to continue joint contracting with insurers on the basis of its clinical integration program.

The move came as a December 2006 consent decree that culminated a four-year government inquiry into the group's practices. FTC guidelines outline two ways that doctors are permitted to negotiate collectively with insurers: through financial integration with risk-sharing contracts or through clinical integration, aimed at setting uniform quality measures to which doctors must adhere to streamline practices and save money.

Previous FTC settlements essentially required physician networks to shut down all their operations and cease contracting altogether. Among roughly 30 actions brought against physician entities for alleged anticompetitive behavior since 2002, one group was permitted to go back and re-do its clinical integration program so that it could continue joint negotiations with insurers on that basis.

Although the FTC's move is not a major departure from its standards, some legal experts say it opens another window into what the government views as acceptable.

The FTC accused Chicago-area Advocate Health Partners of illegal price-fixing in its negotiations with insurers. The group admits no wrongdoing.

The consent decree prohibits AHP from using the messenger model to facilitate any contract agreements on behalf of its 2,900 physician members. But the significance of the order is that it allows the network to continue its clinical integration program, under which it has been contracting since 2003, according to John P. Marren, an attorney for AHP.

UnitedHealthcare and Advocate Health Care Sign New Long-Term Agreement

Wednesday November 21, 2007
-- UnitedHealthcare Members to Gain Access to All Advocate Physician Partners Physicians and Advocate Facilities as Part of the Most Comprehensive Network in the Chicagoland Area

CHICAGO--(BUSINESS WIRE)--UnitedHealthcare and Advocate Health Care, the largest integrated health care system in Illinois, announced a new long-term agreement that will expand access to affordable, quality health care for nearly 1 million Chicagoland residents.

Effective Dec. 1, UnitedHealthcare commercial health plan members will have access to Advocate's ten hospitals:

In addition, UnitedHealthcare customers will have access to Advocate Home Health services, the 800 employed physicians in the Advocate Medical Group, Advocate Health Centers and Dreyer Clinic, and the independent physician members of Advocate Physician Partners.

This new agreement further expands UnitedHealthcare's extensive network to more than 19,000 physicians and 150 hospitals throughout Illinois.

"Our relationship with Advocate will provide UnitedHealthcare customers with broad access to one of the most comprehensive health care systems in Illinois," said Tom Wiffler, president and CEO of UnitedHealthcare of Illinois. "Our long-term agreement reinforces our commitment to working together to provide consumers with predictable and stable access to affordable, quality health care. This is exciting news for our customers in Illinois and Northwest Indiana."

As part of the new agreement, UnitedHealthcare, Advocate Health Care and Advocate Physician Partners will collaborate on several innovative programs designed to promote quality care and support the adoption of health information technology, including an ambulatory electronic health record initiative designed to make digital patient records accessible and improve the quality of care and patient safety while helping reduce administrative costs.

"Advocate Health Care is pleased to be working with UnitedHealthcare to address the health care quality and affordability concerns of employers and consumers in Chicagoland," said Dr. Lee Sacks, president of Advocate Physician Partners. "We welcome UnitedHealthcare into our Clinical Integration Program, and we are confident that this partnership will lead to better health care and service in the communities we are privileged to serve."

Brown & Toland

Brown & Toland and Federal Trade Commission Reach Settlement about BTMG's PPO Business Model

SAN FRANCISCO, CALIF. (February 9, 2004)
Brown & Toland Medical Group and the Federal Trade Commission (FTC) reached a settlement regarding a complaint the FTC filed in July 2003 concerning the medical group's Preferred Provider Organization (PPO) business model.

This settlement allows Brown & Toland to continue to offer a managed PPO product. As part of this settlement, Brown & Toland agreed to offer its contracted PPO plans the opportunity to terminate, however, termination of existing PPO contracts is not required. "We are pleased to proceed forward with our PPO program," said Gloria Austin, Brown & Toland's Chief Executive Officer. "We are continuing to enhance our clinical integration programs for the PPO product to benefit our patients and physicians. "We have focused on enhancing clinical integration of our PPO network by including the ability to audit and report on patient claims data," Austin continued. "Brown & Toland is using this data to improve patient care. We have already launched a case management program for PPO patients. As a result, it is clear that we are well on the way to addressing the issues raised by the complaint. We have put the litigation behind us in order to focus our resources on patient care."

The FTC settlement does not mean there is an admission of wrongdoing. As the FTC noted in its announcement, a consent agreement is for settlement purposes only and does not constitute an admission of law violation.

With the settlement, Brown & Toland Medical Group (BTMG) will continue to operate a PPO program for its network of more than 650 community physicians and their patients.

Contact: Richard Angeloni, Corporate Director, Communications, (415) 972-4307, rangeloni@btmg.com

For more information about Brown & Toland and the FTC, click this link.