:: Administrative Staff  |  Board of Directors  |  History & Philosophy ::

SIHCA Administrative Staff ::

	Mary Nigma, CPC-I Director of Operations		Joy Strathman Financial/Contracts Consultant
	Renay Casey, RHIT, CCS-P Risk Management Operations		Katelyn Raschen Utilization Improvement Coordinator
	Beverly Heidrich Administrative Assistant		Madelynn Purgahn Utilization Improvement Coordinator

SIHCA Board of Directors ::

	President :: James Althoff, MD Family Practice Freeburg, Illinois		Vice President :: Eric Lopatin, MD Family Practice Troy, Illinois
	Secretary :: Patrick Zimmermann Family Practice Collinsville, Illinois		Treasurer :: Guillermo Rodriguez, MD Hematology/Oncology Swansea, Illinois
	Director :: Mark Fedder, MD Gastroenterology Maryville, Illinois		Director :: Morris Kugler, MD General Surgery Maryville, Illinois
	Director :: Wallace Abel, MD Family Practice Belleville, Illinois		Director :: Ryan Diederich, MD Plastic Surgery Glen Carbon, IL
	Director :: Melinda Walker, DO Family Practice Belleville, Illinois		Director :: Stephen Raben, MD Family Practice Mascoutah, Illinois
	Director :: Kevin Barnett, MD General Surgery Belleville, Illinois

History & Philosophy of SIHCA ::

HISTORY

The healthcare delivery system in this country is changing! Physicians are confronted with the uncertainty of a new financial climate. Patterns generated over the years of service no longer guarantee success. Identifying and assessing the impact of external influence is more difficult. Flexibility and adaptation are more essential.

For more than thirty years, the healthcare industry in this country experienced unprecedented growth. The more healthcare, the better the system! Healthcare providers enjoyed professional independence and financial success. Physician office visits increased and hospital bed numbers expanded. Increasing elective care was performed. The population was aging and the elderly required treatment. Entitlement programs were readily funded. Fee for service and cost plus reimbursement were the standards.

Throughout the 1980’s and early 1990’s healthcare costs escalated at double-digit rates, and continue to rise today. The American healthcare delivery system became the second largest industry in this country and the most expensive healthcare delivery system in the world.

Unfortunately, more is not always better! Government and the private sector can no longer afford unlimited care. More than 37 million Americans under the age of 65 have no health insurance and do not qualify for federal or state entitlement programs.

Healthcare reform has been a topic of concern in government and industry for more than a decade. During that time we have seen major revision of the Medicare System and an aggressive move in the private sector towards cost containment. Physicians confronted with competition, price restraints, and fiscal accountability are being forced to meet the challenge of providing cost effective quality healthcare.

As politicians and lobbyists continue to discuss managed competition, employer mandates, and universal coverage, healthcare payers and providers are already developing more sophisticated delivery systems. Employers trying to find high quality, accessible and affordable coverage for their employees are turning toward managed care alternatives.

MANAGED CARE

What is the managed care alternative? Simply stated, a managed care delivery system provides comprehensive health care to a subscribed population of patients using providers who understand the concepts and relationships of cost effectiveness and quality care. In managed care, the economic risk of healthcare is expanded to include, not only the underwriters, employers and the individual, but to variable degrees the providers as well.

There are three basic types of managed care plans:

Health Maintenance Organizations
Preferred Provider Organizations
Point of Service Option Plans

Health Maintenance Organizations (HMO) contract with select groups of physicians and hospitals to provide health care services to its insured subscribers for a predetermined monthly capitation. HMOs restrict patient access to contracted physicians and hospital providers. Subscribers insured under HMO plans experience minimal expense as long as contracted providers provide services. HMOs reduce cost by placing the provider at financial risk and providing financial incentives for contracted providers to control utilization.

Preferred Provider Organizations (PPO) are somewhat similar to HMOs in design, but place less restrictions on patient access to contracted providers. As in the HMO plans, subscribers insured under PPO plans experience minimal expense as long as services are provided by contracted providers. PPOs generally reimburse their contracted providers on a discounted fee schedule. PPO plans do not place the provider at financial risk and have fewer internal controls. Accordingly, the cost savings in PPO systems is less than in HMO systems.

Point of Service (POS) plans are hybrids combining characteristics of both indemnity insurance and HMO plans. The patient can elect to receive service from a contracted provider or a non-contracted, out of plan, provider. Significant financial incentives encourage the subscriber to stay in the plan. However, the patient retains the freedom of choice not found in a traditional HMO model. POS plans offer the least cost savings and are usually offered as an indemnity alternative in conjunction with either an HMO or PPO plan.

SOUTHERN ILLINOIS AND MANAGED CARE

St. Clair County and contiguous portions of Madison County, Clinton County, Washington County, Randolph County, and Monroe County represent a service area population of more than 300,000 people. The current payor mix in these communities is believed to be thirty five percent (35%) Medicare, thirty percent (30%) commercial, twenty five percent (25%) managed care, and ten percent (10%) is Medicaid eligible.

Managed care activity in this broad geographic area has been primarily limited to PPO contracting. However, local employers are now looking for underwriters and provider groups who can offer all three managed care options.

Economic pressures are driving local industry and the private sector to managed care. More importantly, the federal government is actively supporting the expansion of Medicare managed care plans and the State of Illinois is encouraging the further development of Medicaid managed care plans. With these factors considered, it will not be long before managed care payments represent the majority of medical service revenue.

There are two acute care hospitals in Belleville and seven additional hospitals located in the adjacent communities. All are preparing for increased managed care activity.

Located across the river from St. Louis, the Southern Illinois medical community is not only affected by local factors, but is also strongly influenced by activity in St. Louis. The St. Louis managed care market has developed over the past fifteen years and plans are in progress to bring more contract opportunity to Southern Illinois.

Strategic plans for most physicians and physician groups look significantly different today then they looked ten years ago. Instead of focusing on product lines and increased volume of service, strategic plans now call for cost reduction efforts, utilization management programs, managed care initiatives and the development of new organizations to support these initiatives.

These organizations call for a partnership between physicians. Providers know that they must be prepared to meet the demands of managed care and through these organizations, healthcare providers can more effectively pursue managed care opportunities. Providers who prepare quickly and prepare well will have the best chances for success.

Southern Illinois Health Care Association was founded by concerned physicians to specifically represent the collective interest of its members in addressing and pursuing managed care opportunities. SIHCA already has two hundred fifty (250) physician members and continues to grow. Each member provider is independently contracted to SIHCA to provide medical services to patients subscribed in managed care health plans contracted by the organization and the organization is empowered to act as the contracting agent on behalf of all its member providers.

SIHCA presents a comprehensive package of health care services attractive to managed care underwriters, third party payers, employers and individuals. SIHCA is dedicated to providing comprehensive, cost-effective, quality health care services to the communities it serves.

DESCRIPTION OF BUSINESS

Southern Illinois Health Care Association (SIHCA) was incorporated April 11, 1995. The organization was developed to provide a mechanism for its participating providers to collectively broker their services to managed care underwriters by acting as the contracting agent for those participating providers.

Contract opportunities developed by the SIHCA will allow its participating providers access to patients subscribed in a variety of alternative delivery system products including specifically, but not exclusively, HMOs and PPOs.

SIHCA currently holds contracts with the following managed care underwriters:

Commercial Contracts:

Blue Cross Blue Shield of Illinois

• HMOI

• Blue Advantage

Aetna Medicare

Health Alliance – Messenger Model

Medicare Risk Contracts:

United Health Care Medicare

Essence Health Plan 

COMMITTEES

Medical Management/Clinical Integration Steering Committee

The Medical Management/Clinical Integration Steering Committee has the responsibility and authority to coordinate, appraise and perform utilization and quality management functions. The Committee is responsible for quality assurance, utilization review, risk management, peer review, and continuous quality improvement. The Committee reviews physician applications for membership in SIHCA and recommends physician recruitment and membership policies to the Board of Directors.

Patrick Zimmermann, M.D. (Family Practice), Co-Chairman and Associate Medical Director

Paul Reger, M.D. (Family Practice), Co-Chairman and Associate Medical Director

Kenneth Eakin, M.D. (Family Practice)

Aaron Greenspan, M.D. (Gastroenterology)

Eric Lopatin, M.D. (Family Practice)

Kyle Shepperson (General Surgery)

Jeffery Chalfant (Behavioral Health Medical Director)
 

MEDICAL PROVIDER PARTICIPATION CRITERIA

Southern Illinois Health Care Association has established an objective set of criteria for the selection of physicians, dentists, and allied health professionals for participation in the IPA. These criteria reflect the commitment of the organization to develop a provider panel of well-trained, highly qualified practitioners who understand the principles of cost effective, quality health care. These criteria will be used as the basis for initial provider selection and along with peer comparison performance evaluations will be used as the standard for continued participation.

When initially approved, providers are awarded provisional status pending their first formal credential and performance review. Formal credential and performance reviews will be performed every two years or more frequently as determined by the Board of Directors.

DEFINITIONS:

* At the discretion of the Board of Directors, and Internal Medicine subspecialist who practices primary care may participate as a Primary Care Physician and Specialty Physician.

THE FOLLOWING CRITERIA HAVE BEEN ESTABLISHED AND ARE REQUIRED FOR PARTICIPATION IN SOUTHERN ILLINOIS HEALTH CARE ASSOCIATION

• APPLICATION

Medical providers making application must submit a completed, signed, and dated Provider Application with all required supporting documentation. All documents listed in the application section must be supplied for consideration along with a signed SIHCA Participation Agreement or Contract. Once completed and submitted, the physician’s credentials will be reviewed by the Clinical Management Committee. The Committee will make a recommendation to the Board of Directors based on the existing criteria for participation in SIHCA. The Board of Directors has ultimate authority. All participating providers must agree to provide the IPA with updated personal and professional information when requested for future credential reviews.

• PROFESSIONAL BACKGROUND AND TRAINING

It is the goal of the IPA that all participating providers will be board qualified and eventually board certified according to the requirements of their practice specialty.

In specific cases when a physician applicant is not board qualified or certified, the Board of Directors of the IPA will review the applicant’s file and shall consider some or all of the following in determining the physician’s eligibility to participate in the IPA:

• Satisfactory completion of the requisite years of residency training within the applicant's designated practice specialty.

• Active practice in the designated practice specialty for the five (5) years immediately prior to making application to the IPA.

• Letters of recommendation from the physician's department chairperson and from board certified physicians participating in the same designated specialty.  Letters must state that the applicant is recognized as a specialist and is engaged in the practice of the designated specialty.

• Demonstration of twenty (20) hours, level one, CME credit in each of the two years immediately prior to making application to the IPA.  CME credit must be in the applicant's designated specialty and satisfy the requirements of the State of Illinois, AMA, or American Academy of Family Practice.

• Active participation in academic instruction of the applicant's designated practice specialty.

• Membership in the appropriate medical specialty society.

• Determination of necessary participation for geographic, specialty, or continuity of care reasons.

Physicians who completed their residency or fellowship training after August 1, 1993, must become board certified within the amount of time required by the appropriate American Specialty Board. Physicians. Physicians who were not board certified by January 1, 2001 must petition the Board of Directors for special approval to continue as an IPA participating provider.

• LICENSURE

All participating providers must hold a current license in the State of Illinois and other states as necessary for their practice. All providers must have current DEA and state controlled substance registration.

All participating providers must remain eligible to treat Medicare and Medicaid patients.

• MALPRACTICE COVERAGE AND HISTORY

All participating providers must have at least $1M, $3M malpractice liability coverage.

All participating providers must provide full disclosure of their malpractice history explaining the details and disposition of any and all cases that have come or are coming before the applicable board in any state where the applicant has practiced. All participating providers must have a malpractice history consistent with the high standard of care established by the organization.

• MEDICAL STAFF STANDING

All participating providers must be members in good standing of the medical staff and have attending staff privileges at an IPA participating hospital or other JCAHO approved facility.

• PATIENT ACCESS

All participating providers must have reasonable office hours and be willing to assimilate patients enrolled with the IPA into their practice. Providers must arrange for approved coverage of their patients when they are unavailable.

• UTILIZATION, COST, AND QUALITY

The IPA is committed to enhancing the quality of the care delivered to all patients and will develop and implement continuous quality improvement programs.

All participating providers must comply with all utilization review and quality assurance policies set forth by the IPA for all patient services.

All participating providers must agree to participate in the peer review process and abide by the remediation and sanction policies of the organization.

ELIGIBILITY DOES NOT GUARANTEE PARTICIPATION. EACH APPLICANT IS REVIEWED ON INDIVIDUAL MERIT BY THE UTILIZATION MANAGEMENT COMMITTEE. THE NEEDS OF THE ORGANIZATION MAY INFLUENCE THE FINAL DECISION OF THE COMMITTEE.

CONFIDENTIALITY OF MEDICAL RECORDS

Southern Illinois Health Care Association will comply with all applicable laws, regulations, and ethical principles concerning the confidentiality of medical records. Providers must hold all information pertaining to medical records in the strictest confidence.

PROPRIETARY INFORMATION

All policies, procedures, guidelines, and forms represented in this Manual have been developed for the explicit use of Southern Illinois Health Care Association and are the sole property of Southern Illinois Health Care Association. The reproduction, distribution or unauthorized use of any information contained in this Manual without the written approval of Southern Illinois Health Care Association is prohibited.

Southern Illinois Health Care Association shall retain all rights, title and sole interest in all confidential information, documents and intellectual property owned or created by Southern Illinois Health Care Association that may be furnished from time to time to Southern Illinois Health Care providers. Providers possessing knowledge of any confidential information, documents or intellectual property must hold such in the strictest confidence.