When asked to address the nature of an IPA on the SOAPM list recently, this is what Chip Harbaugh (the other Chip Har...) had to say. It is worth repeating. I have taken mild grammatic liberty

Medicine, and especially pediatrics, has become a very difficult area over the last 10 years. We as pediatricians went into medicine (pediatrics) to cure the world one child at a time. We knew what that the pay stunk compared to our peers in the subspecialties, but we signed on to pediatrics because we believed in our mission. We are true doctors - healers- who always place the patient first irrespective of reimbursement. However, as the landscape changed on 9/11, the medical landscape also was altered when the payers became for-profit. The payers and providers have divergent goals. Doctors want to place as many resources as possible to improve our patients state of health while the payerss souls are shackled to Wall Street.

Having realized this a few years ago, I realized that the playing field would never be level. The payers can merge and accumulate market share while physicians must remain independent and fragmented. It is reminiscent of the Cold War. Thus, physicians must work together to effect change both clinically and financially. Pediatricians know medicine better than anyone else, so let us determine medical policy. Payers usually understand the actuarial aspect of business better so we should partner with them to implement our the physician driven healthcare initiatives. This detente works in markets where there is an economic steady state where docs and payers partner to effect change.  If the market has eroded to the point of imbalance, such as in the political state of Iraq, then certain measures are no longer valid and more radical change is necessary.

The ideal environment is where doctors desire change and can aggregate to submit each individual's will and practice pattern to the will of the community standard. This will expose each individual doctor's practice pattern to the group and thus raise the standard of care in the community.  For example: No more calling in antibiotics over the phone because the doctors in the community, as well as the IPA quality review board, see the pattern and thus extinguish the pattern. The best means to effect change is a group of pediatricians IPA (or some other merged entity) challenging pediatricians to challenge other pediatricians to better their own practice patterns to better their own patients outcomes. This desire to be the best clinician among great doctors is what we all desire to be. We do not tear down other doctors but desire to learn and
incorporate the best practices into our daily lives. This should be the spirit of your IPA. This is what drove my passion and our IPA (Kids First) to be what our patients want us to be. Armed with this passion you can achieve a lot.

Forming an IPA, or any merged group along the continuum, will take a lot of self sacrifice (willing to give individual needs to the better good of the community of pediatrics) among the pediatricians in the market, as well as the leaders (no pay for years of many many years of work), perseverance against all obstacles, and a true desire to effect change in the overall delivery of healthcare (not to just increase reimbursement rates). If your motives are pure and the medical environment is right then forming some larger medical entity will play heavily in your favor.

Each market is specific to the timing of the payer climate as well as
the provider environment. Researching your market and assessing your needs will allow you to better to develop a model that will best serve you and your patients needs.

I've had some great discussions with Dr. Harbaugh and we've never had enough time to complete them.  Although I don't agree with him 100% time - who ever does? - here's why I like this message:

• He  refers to non-pediatricians as subspecialists, which implies that pediatricians are specialists.  Which they are.  I can't stand it when I hear pediatricians refer to everyone else as a specialist and themselves as...nothing special?  Pediatricians are specialists.  Important specialists.
• He has poinpointed a fundamental problem with our healthcare system: its dependence on Wall Street.  The goal of the publically traded company and the healer are at odds.
• He mentions clinical change ahead of financial change.  Clinical change is the driver for financial change.  Look at this great quote: Pediatricians know medicine better than anyone else, so let us determine medical policy.  Awesome.
• In particular, pointing out the clinical competition that an IPA should take is very poignant.  The best (only?) good IPAs I know think this way.
• Finally, this ought to be run by almost any merging group: Forming an IPA, or any merged group along the continuum, will take a...true desire to effect change in the overall delivery of healthcare (not to just increase reimbursement rates).

Great stuff, and thanks to Dr. Harbaugh for letting me share.