Physician Reimbursement

PDA physicians work hard. They are good stewards and try to stay ahead of what is going on financially.  And, there is much information to follow on reimbursement, politics, health system integration, and information technology. For example, reimbursement is a major issue because practitioner compensation is decreasing.  It is not difficult to understand why reimbursement is not keeping pace with expenditures and fully-expensed practice costs.  Many physicians are trying to supplement income by working harder and generating more volume.  Others are throwing in the proverbial towel and asking for a time card to punch.  PDA can provide better alternatives.

Reimbursement is generally based on government-funded managed care, i.e., Medicare payment schedules.  Commercial insurance, through avenues of HMO, PPO, and other managed care, tends to track or at least relate with physician reimbursement as a percent of Medicare.  That problem is compounded by the legal restrictions on “messenger model” IPAs which have no power to negotiate for more favorable contracts.  Therefore, PDA and all other IPAs in this geographic region have about the same level of reimbursement per CPT code.  Confidential feedback from market sampling and billing advisors shows that there is near-complete regional uniformity in IPA reimbursements to physicians.  Locally, none of the IPAs in the DFW market can gain a competitive advantage with regard to reimbursements.

As would be expected, reimbursements are trending downward nationally.  Plus, there is a government initiative to further accelerate the cuts.  What can an IPA do?  What are the competitive difference makers for the physician?

As previously stated, an unsatisfactory answer is to work harder and make it up with volume.  Let’s contrast that to participating as a businessman in a program that has upside reimbursement, investment opportunity, and bonus potential.  PDA is looking at a number of options that build on the physician’s training and intellectual firepower.

PDA wants to visit with you about these opportunities:

  • Medicare Advantage plans that have successful records for physicians
  • Transitional care centers
  • Wound care
  • Company physician positions
  • Benefits provision
  • REIT investments
  • The Medical Home concept
  • Telemedicine

Our physician team is ready to discuss these opportunities.   Please call today.


The Miers Group – PDA : A Professional Achievement Announcement

The combination of a physician’s healthcare knowledge with an understanding of the insurance industry is the foundation of The Miers Group (TMG).  The eclipsing green orbs in our logo graphically represent the interdependence of healthcare delivery and the financing of benefit solutions. TMG is the management services organization (MSO) that represents the Physician Direct Access IPA.  A unique aspect of PDA’s service for its physician members is the access to benefits solutions.

Towards professional superiority, The Miers Group is proud to announce that Daniel S. Karin, M.D. has completed the requirements for licensure as a Life and Health Insurance Counselor.  This licensure allows him to examine, advise, and make recommendations regarding health insurance, life coverage and employee benefit plans.  Other names for this level of training and expertise include “insurance analyst” and “insurance specialist”.  In addition to developing the benefits consulting practice for TMG, Dr. Karin also is licensed as a Life and Health Agent as well as a Property and Casualty Agent (giving him insider knowledge of medical malpractice insurance).  To put this achievement into context, note that at the end of August, 2010, there were 421,502 agents, agencies, and adjusters licensed in Texas but only 523, a tenth of a percent of these professionals, are licensed Life and Health Counselors. 

Dr. Karin serves as a practice leader in the specialty of anesthesiology.  He also is the TMG Medical Director and serves as a Board Member of the Physician Direct Access IPA.  Dr. Karin is a member of the American Institute for Healthcare Quality.  In total, he represents the fusion of healthcare delivery with practical improvement of plan designs, patient needs, and utilization review.  The TMG organization hails this accomplishment for our clients.

In Support of Direct Contracting:

Direct contracting representation for PDA physicians is under the banner of the “Flagship Physician Network”. The expertise of Dr. Karin as both a physician and counselor will be essential as plan design, disease management and cost concerns are sculpted to assist the client companies and their employees. Flagship practitioners will have a direct communications avenue to the process as managed care evolves to collaborative care.


Not just an IPA

Not just an IPA……………………

In this time of ObamaCare medicine and Medicare/Medicaid program change, the traditional IPA is quite unremarkable. There must be more to the IPA service menu than a smiley face, credentialing, and similar messenger-model discount contracts.

Physicians want to be heard on issues in their local market.  They also seek better financial rewards with less labor and hassle. And, they want more from their IPA. PDA is responding to that need. As an emerging IPA, PDA is performing the expected traditional services, but is also morphing into an action driven revenue machine.

PDA is committed to developing new strategies and action plans for the marketplace.  It is on the cutting edge of new ideas, and it studies the success of others as well.  The development of community-based health plans led by physicians with insurance agent licenses is catching the attention of other providers.  A local acute care hospital system has begun presenting Physicians Direct Access as their preferred IPA.  They see that PDA has all competitive contracts with the leading managed care insurers, first-class service and offers a value entry price.  Additionally, PDA is partnering with the hospital system and its entire Dallas market to design a narrow commercial self funded product that will be of benefit to the hospitals, their medical staffs, and local small employers and citizens.

This is big news for PDA. It underscores the hard work to make a difference. It is game on. You’re invited to help in the re-invention of independent physician organizations.


Repairing Healthcare

Barak Obama campaigned on the promise of renewed hope and new social programs. Leading the way was the promise to reform America’s healthcare system.  Indeed, we now have a law that was essentially unread by Congress before it was passed. And, the conflict over its content rages today.

ObamaCare intends to expand government health insurance to 40 million additional beneficiaries who were not previously covered by health insurance.  However, President Obama has managed to declare the expansion as a successful effort without an attempt to reduce the underlying cost of healthcare.  True reform demands that we address the underlying issues.  Why are healthcare costs bankrupting our Nation? 

Our third-party payor system is at the root of the problem.  The authors of healthcare benefits have gone on a tangent so that the purchaser of healthcare (the patient) is no longer the payor.  The patient is no longer constrained to consider the price of his purchase, and the seller (hospitals, physicians, etc.) are no longer bound by free market principles. 

Health insurance (and all forms of insurance for that matter), is designed to spread the risk of loss over a large population.  An individual can face the risks of unplanned medical events by himself, or he can join a group of individuals who pool both their risk and resources.  They know that someone in the group is statistically likely to need the help while the others in the group could have escaped with no payment at all if they had not joined. But today, insurance is no longer a simple hedge against a statistically possible disaster.  Today, insurance has expanded to cover first-dollar expense.  As a result, the premiums are now far higher than they would otherwise be, and they are continuing to rise. 

We have come full-cycle so that higher deductibles and copayments are creeping back into the picture, but the damage has been done.  The free-market linkage between providers and patients has been broken.

The Flagship Physician Network is not a revolutionary, new way to provide healthcare.  Rather, the Flagship is bringing a wonderful system back into play. The Flagship controls medical costs by recreating the traditional link, a direct contract between patients and providers, while using the employer as the sole intermediary.  

The free-market system still has a place in our society.  Government-controlled medicine will simply add grease to the fire.