Proposed Consent Agreement: Boulder Valley Individual Practice Association, et al. #539810-00001

Submission Number:
Wendy Spirek
Spirek Managed Care Consulting
Initiative Name:
Proposed Consent Agreement: Boulder Valley Individual Practice Association, et al.
As a consultant, I have been involved in Provider Network Development efforts in 2006, 2007 and 2008 assisting Heritage Health Systems (or its parent, Universal American Financial Corporation) introduce a managed care Medicare product to Boulder County. CMS requires contracts be held with key specialty providers in order to grant license for a payor to offer and sell a Medicare Advantage benefit program to Medicare Beneficiaries. 2006 attempts to contract physicians on an individual level netted consistent responses from the invidual practices that they only work through BVIPA. During 2007 and 2008 attempts, Boulder Community Hospital refused to contract with Heritage Health Systems unless BVIPA signed an agreement. In each of these attempts, BVIPA's management staff never agreed to present to its Board the company's offer, resulting in a "message" to participate sent to its physician members. BVIPA's management staff refused to present to its Board the company's offer of rates unless rates were negotiated 5% to 15% higher than base Medicare rates for a Medicare Advantage product. In 2008, BVIPA's Management staff agreed, for a fee to the IPA, to issue an "endorsement" of a contract (containing language pre-negotiated by the IPA's management staff and the payor) presented to the individual practices. It is well known that even though the IPA "endorses" a individual contract, given the IPA's governance didn't messenger the contract at the IPA level serves as a notice/warning to its physicians that rates offered would not meet (ie lower) than what the IPA governance would accept at a Board level. There are untrue statements issued on the IPA's website announcing the FTC action given my experience working with the IPA in years past as articulated in this comment. BVIPA's member physician practices have a history of deferring payor contract invitations issued indivdually to the IPA. BVIPA's management staff and its Board have a history of refusing contract invitations at Denver metro market rates resulting in no message sent to its members of a payor's contract invitation, other than taking advantage of BVIPA's offers of a payor paid endorsement. I would submit, if an actuarial study were done comparing professional services costs providing similarly available healthcare in surrounding counties versus Boulder County, the figures would be categorically higher with no clinical differential indicating improved quality of care. Premium costs are higher caused by higher provider rates and there is a distinct lack of competiting payors available in Boulder County for invididual seeking to offer health care benefits to their employees and familes. This results in a premium locked community. Here are statements they've posted on their website, dated 12/24/08 you.