GRIPA, an organization that includes 812 Web-portal-connected physicians and their two affiliate hospitals, 494-bed Rochester General Hospital and 83-bed Newark Wayne (N.Y.) Community Hospital, has been working for nearly three years to take advantage of its federal approval to operate as an independent practice association, an organization of competing physicians seeking joint fee-for-service contracts with private payers.
In September 2007, GRIPA became only the second clinically integrated IPA to get a favorable advisory opinion (PDF) from the Federal Trade Commission. At the time, the organization's IT-dependent business model was hailed by some as the wave of the future. But after almost three years, there are only two clients GRIPA can claim: the employees and dependents of the Rochester General Health System, of which the IPA is a part, and LiDestri Foods, a 700-employee manufacturer of sauces, dips and other private-label and brand-name products.
"There's no guarantee that when you build a better mousetrap that someone is going to buy it," says David Narrow, a lawyer in the healthcare division of the FTC Bureau of Competition.
The Rochester market is dominated by two payers—Excellus Blue Cross and Blue Shield and MVP Health Care—and some observers have blamed GRIPA's small client base on the payers dragging their feet. Eric Nielsen, GRIPA chief medical officer, doesn't necessarily disagree. "That's not wrong, payers have been dragging their feet," Nielsen says, adding that executive turnover at Excellus has also slowed negotiations.
Excellus spokesman Jim Redmond, however, says leadership changes at GRIPA also had a role. He says the biggest factors have been the recession and uncertainty over healthcare reform.
"Excellus BCBS remains very interested in the model the GRIPA represents, and we have been in dialogue with them for more than a year," Redmond says in an e-mail. "The conversation did slow for a few months while the entire country awaited direction on national healthcare reform and more definition of the role of accountable care organizations. Now that a broader understanding is starting to emerge, we are speaking not only with GRIPA but also with a number of interested groups of hospitals and physicians throughout upstate New York (our service territory) about how we can best support their development."
Meanwhile, GRIPA's Nielsen says that a contract with MVP is "off the table." GRIPA is looking elsewhere now and has sought to create diversity in the market by recruiting three new Medicare Advantage plans to do business in the region and is looking to add more self-insured large employers, Nielsen says.
"We have several other contracts pending," he said. "We had hoped to get employers to approach the payer, and they said, 'Why bother? Just go to us directly.' What the payers have been telling us is that employers wouldn't accept a limited panel (of physicians), but that's not true—there's been a bending of the trend." Nielsen says about 35% of the community's physicians are affiliated with GRIPA, but because the IPA contract for clinical integration is nonexclusive, payers go around the organization and contract individually with its doctors.
Christi Braun, a principal with the Ober Kaler law firm's antitrust and competition, litigation and health law groups, agrees. "GRIPA has definitely faced challenges in getting managed-care contracts—they're not alone with that," said Braun, who represented GRIPA in its dealings with the FTC. "There are a lot of payers who, despite giving lip service to wanting higher-quality care delivered to patients, are not willing to pay for higher quality."
Braun adds that payers also don't know how long patients will stay enrolled in their plan, so "they have no reason to believe paying for preventive care will benefit them."
GRIPA members use a secure, Health Insurance Portability and Accountability Act-compliant physician Web portal and database to share and store patient information—including clinical data from office visits and hospitalizations, laboratory results and diagnostic imaging, Nielsen says. And he explains that the database is then used to generate physician quality reports on preventive medicine and care management according to physician-created, evidence-based guidelines.
“What we have and what we started out building was not an electronic medical record, but a portal to share information between offices,” says Nielsen, noting that what most electronic health records do is “capture data and do billing” with limited capability for sharing information. The GRIPA portal and database, however, can perform sophisticated analysis of the information it captures—which Nielsen said is what HHS is trying to get EHRs to do with its meaningful-use criteria.
"Having that database has been powerful," Nielsen says. "What we have is what the meaningful-use requirements are looking for—only we're doing it with a portal and analytics, not necessarily an EMR."
In theory and from the FTC's standpoint, the GRIPA approach will improve outcomes and lower costs, but Nielsen acknowledges that the association's small client base has not yielded enough data to prove its case—which has also hindered GRIPA's growth. "If they insist on seeing outcomes data before the contract with us, it's a Catch-22," he says. "But we don't have a lot of data because we don't have a lot of members. The guys at the FTC are asking us, too: 'When are you going to publish some data?' I say we don't have it yet."
In contrast, Oak Brook, Ill.-based Advocate Physician Partners, which is believed to be the largest clinically integrated IPA with some 3,400 doctors and eight hospitals, has five years of "value reports" posted on its website. According to the 2010 report (PDF), the clinical integration program's asthma outcomes initiative saved $16 million based on national cost averages and resulted in an estimated 37,920 days saved from absenteeism and lost productivity. The report also states that the organization's generic drug-prescribing initiative saves payers some $14.8 million annually.
Advocate Physician Partners has contracts with 10 payers in the market—including Blue Cross and Blue Shield of Illinois—and has chosen not to seek the business of large self-insured employers. Mark Shields, Advocate vice president for medical management, says the group has been encouraged by the FTC to talk about its program with providers and policymakers. "I'm not an antitrust lawyer—I'm a doctor—but I've been hanging around antitrust lawyers for about five years," Shields says. He said that doctors are not allowed by the FTC to work together on setting prices for services unless they are sharing financial risk or they are clinically integrated and working together to add value to the marketplace by increasing quality and lowering costs.
"The doctors don't view each other as competitors, but the federal government does," Shields says of the physicians in the Advocate group. "In the view of the FTC, doctors of the same or related specialty in the same geographic area are competitors."
Shields said Advocate Physician Partners has several IT-connected programs where doctors are collaborating to improve quality and cost efficiencies, including care programs for asthma, congestive heart failure, diabetes and preventive pediatric services.
"We have 116 different measures that we rate doctors on," Shields says. "We provide a lot of IT infrastructure so doctors can communicate with and track patients."
In January, it was announced that GRIPA's Nielsen was named a senior medical adviser with the Camden Group healthcare consulting company with a specific expertise in IPAs in general and GRIPA in particular.
Laura Jacobs, a senior vice president with the Camden Group who has advised the Brown & Toland Medical Group clinically integrated IPA in San Francisco, says clinically integrated IPAs have risen in importance as they can be viewed as a base upon which to build an accountable care organization. An IPA "gives physicians the tools to better coordinate and manage care," she said.
"The key is that the organization has a robust capability to gather this clinical information and to use it to monitor physician quality and to monitor costs," Jacobs adds. "Clinically integrated means you really are measuring quality—and not in a passive way."
Another Camden Group senior vice president, James Smith—also a former senior executive with both GRIPA and Excellus—says the speed at which GRIPA has grown needs to be put in perspective. "From the outside, everyone is moving slow," Smith says. "But if we measure it and are accountable for it, we'll move to something that will help our country and help the (healthcare) system. I think the main obstacle is that there is a short-term focus by all of us."