2014 STATE LEADERSHIP CONFERENCE
contract probably isn’t even necessary,” he said. “You could just
go to the entities and say, ‘I’m here for you.’”
• Co-location. The next step up is sharing or renting office
space with potential referral sources, either part- or full-time.
While still easy to do and low risk, this model usually involves a
• Independent practice association (IPA). In this model,
independent practices come together to achieve common goals.
Often that means having the IPA contract with a managed-care organization or health system to provide services. While
this model may give psychologists access to more opportunities
than they could achieve on their own, there are more legal risks,
including antitrust concerns.
• Management services organization. These are like
“IPAs on steroids,” said Ryan. The organization is a separate
legal entity — often with its own name and branding —
that develops a network of providers that can contract with
multiple payers on a much broader geographic scale. (An IPA,
in contrast, typically contracts with a single payer or hospital.)
Creating a management services organization involves much
more legal risk, Ryan warned, citing multiple contracts and the
potential risks of marketing under a common name.
• Accountable care organization (ACO). Though
some psychologists may consider participating in an ACO,
psychologists aren’t likely to put together an ACO themselves.
The extensive ACO requirements tend to be more hospital-,
primary care- or physician-oriented, said Ryan.
• Merger. In a merger, two entities become one or form a
new entity. Or one entity simply acquires the other. “Mergers
are the ultimate in clinical and financial integration and the
highest legal risk,” said Ryan. Plus, they’re much harder to get
out of than the other models. At this end of the scale, he added,
the model is not a joint venture but a single legal entity.
“As you go up the scale, you get increased risk and liability,”
said Ryan. “Where you want to jump on this train depends on
your own risk tolerance.”
Some psychologists have already made that jump. At one end
of the spectrum, the Rhode Island Psychological Association
(RIPA) is creating a behavioral health referral network, said
RIPA President Peter Oppenheimer, PhD. Much higher on the
spectrum, Keith A. Baird, PhD, and colleagues are developing a
more elaborate model. The organization they’re creating hopes
to become the behavioral health-care provider for many of
northern Illinois’s ACOs and to lower health-care costs while
Somewhere in between those two extremes is the model
involving co-location and referral contracts described by
Michael Goldberg, PhD, founder and director of Child and
Family Psychological Services Inc./Integrated Behavioral
Associates in Massachusetts.
For Goldberg, the transition from a simple, traditional
practice to a full-fledged alternative model came in stages.
The practice began with Goldberg as a traditional solo
practitioner. He added a couple of group members in 1994. In
2005, a physician who often referred patients to the practice
agreed to rent them space in her office to see pediatric patients.
That co-location model is still going, but now the practice is
also integrated into three primary-care offices, a neurology
office and an obstetrics/gynecology office in addition to the
practice’s two independent outpatient behavioral health offices
with Goldberg’s practice accepting most of their mental health
“When I talk to other psychologists, I often hear, ‘I’m a small
practice or a solo practitioner; I can’t do that,’” said Goldberg.
“That’s absolutely incorrect and self-defeating thinking.”
This integrated practice model requires just three legal
components, said Goldberg. One is a base agreement that
defines the goals of the two entities. The second is a lease for
the shared office space. The third is a service-specific agreement
to cover services that aren’t covered by the traditional, fee-for-
service arrangement, such as having a geropsychologist make
house calls as a way of keeping patients out of the emergency
Developing this model was really pretty simple, said
Goldberg. “You can do it in a step-wise manner,” he said.
Of course, there are serious antitrust issues to consider when
economic competitors come together in a venture that jointly
negotiates fees with insurance companies or other entities,
warned Alan Nessman, JD, senior special counsel in the APA
Practice Directorate’s Office of Legal and Regulatory Affairs.
“Price fixing is normally considered bad because it decreases
competition, increases prices and brings higher costs to
consumers,” Nessman said. But, he explained, the antitrust
agencies recognize that “properly integrated collaborations
promote cost-effectiveness, lower prices for consumers and
improve quality and that some ventures will need joint
negotiation to be viable.” As a result, the agencies have issued
guidance on the integration necessary to keep collaborations
out of antitrust trouble.
The key is sufficient financial integration — substantial
sharing of financial risk — or clinical integration that
achieves higher quality, lower costs and more efficient
delivery of health care. Most psychologists prefer the clinical
integration route, said Nessman. There are a dozen elements
of clinical integration that collaborations should include,
such as development of clinical protocols reflecting current
developments in treatment and measureable goals to monitor
the quality of treatment provided. APA Practice will be
providing more details on these elements and other issues in
the near future, he added. n
Rebecca A. Clay is a journalist in Washington, D.C.