An Oncologist’s Postmortem of An IPA That Failed to Flourish

ORLANDO--A group of San Diego County oncologists, spurred by the rapid advancement of managed care in California, felt they were taking the right step in forming an independent practice association (IPA) known as the Cancer Care Specialist Medical Group (CCSMG). But the group failed to survive. Joel Lamon, MD, a founding member, conducted a postmortem of this IPA at ASCO’s fall educational meeting.

"We formed the CCSMG to develop and manage a network of medical oncol-ogists in order to enter into risk-sharing agreements with HMOs and other payers," said Dr. Lamon, of Southwest Cancer Care Medical Group, Poway, Calif.

The group began with a few ground rules about who could and could not join: It would be open only to medical oncologists initially, with a long-term look toward adding radiation oncologists and others. Barred from joining were physicians employed by a hospital or any entity with which the IPA might contract, physicians belonging to a closed model HMO, and those who would not allow the IPA to negotiate their contracts.

With those rules in place, physicians were recruited, based on reputation, prior acquaintance or friendship with the founding members, and geography.

While on the surface it seemed that everything had been well thought out, the group did not flourish. "Because of the collegial aspect of our group, we made unrealistic compromises," Dr. Lamon said. For example, the group decided that the best terms of any member’s current contracts would be proposed in contracting, and no member would be required to compromise his or her current terms.

Again because of the fraternal nature of the group, there was no strong administrative leadership, and meetings became bogged down in minutiae. "The same problems would be discussed over and over; there was little or no compromise, and things never moved forward," he said.

A fatal misconception of the IPA was that it should only be contracting with new payers covering larger geographic areas and not with payers that were already the source of contracts with individual members. Members also felt the IPA should not compete for contracts they already had or renegotiate terms.

‘There Are No New Patients’

Members felt the IPA should only provide new patients, as that was ostensibly why they had joined. Other members would explain that one physician’s new patient was their old patient. In reality, he said, "there are no new patients."

The group should have taken a longer view, Dr. Lamon believes, focusing on new contracts and new ways of delivering care. Instead, he said, "we focused on preserving each physician’s autonomy." Further, he said, "this IPA was not well equipped to provide innovation."

For an IPA to work, there must be a commitment beyond the initial contribution and well-defined organizational goals. Because of the fraternal aspect of the CCSMG, he said, no one seemed willing to compromise another’s autonomy for the overall long-term good of the group. "There was variable commitment to group contracting," he said. "There has to be a full commitment to having the IPA act as a contracting agent; otherwise, the group focus is lost."

Finally, Dr. Lamon said he didn’t feel the group was selective enough in choosing its members; only those willing to make a commitment to the voluntary effort should have been let in. The last words of a dying organization, he said, are "we never did it that way before."