Medical Management–The New Normal

As of last week, some of the largest companies that were providing Medicare Advantage enrollment were:  HealthSpring, United Health Care, Aetna, Humana, Wellcare, Amerigroup, Coventry Health, and Universal American.

 The Cigna conglomerate has acquired HealthSpring for a purchase price of 3.8 billion dollars ( Cigna’s stated objective is comprehensive product representation that will enable profitable market penetration of the senior market.

 The “new normal” of healthcare marches forward day by day.  On the one hand, physicians are being acquired by hospital systems as the systems integrate vertically and horizontally.  On the other hand, physicians who wish to remain independent, but passively accepting traditional patient sources, must rely on the reimbursement provided at the whim of government and commercial insurers.  PDA is committed to bring new profitable business without added hassle and work requirements to its represented physicians.

 The obvious solution for the independent physician is to learn how to survive and even flourish in the new normal.  Seeing one patient at a time won’t get the job done.  Cigna knows that they have acquired a profitable business model for senior medical care which can easily be extended to the commercial insurance market. HealthSpring’s value comes from its management’s ability to work effectively with physicians and with patients.  This is accomplished by helping its physicians deliver effective care through medical management while ensuring patient satisfaction.  That’s 3.8 billion dollars’ worth of knowing how to work together.  Impressive….

 PDA can see similar success by interfacing physicians, patients, and medical management.  That’s why we’re working with Universal American to gain access to Medicare Advantage programs.  This is a learning experience for PDA, and we are seizing the opportunity because medical management to optimize healthcare efficiency will become a part of every insurance plan.  This is a difficult pill for physicians who grew up in “the golden age of medicine”.  Each physician practicing in the 70’s, 80’s, and 90’s developed a personal style of practice. 

 But now, the “new normal” has to be better, both functionally and financially.  Those of us who complained about “best practices” and “medical management” have been given pause, and rightly so.  It is clear by the success of the HealthSpring that physicians can work together with excellent data  to provide optimal care at optimal price.  No one single physician can gain enough personal experience to match these results. PDA is committed to refining these thoughts to action plans and specific pathways to success.

Upgrading Medicare

We thank our primary care physicians for enthusiastically embracing PDA’s new Medicare
Advantage program, Texan Plus.  Even though it’s officially called an “HMO”, it gives us the opportunity to increase the cash flow from current Medicare patients without increasing hassle or time commitment.  That satisfies our pledge perfectly.  Some with available capacity in their practice may even find that they have an interest in adding to their Medicare load, but that’s a
secondary consideration.  For those who have not yet responded, please be aware that we started the credentialing process today.  For those PCPs who would like us to enroll selected specialists for their referral network, just send us a list of names.  The specialists can benefit from this program as well.

Next on the agenda will be our “Narrow Network”.  We will be rolling it out in Rowlett/Rockwall, in Frisco, and in the East Dallas market.  This is an exciting time in medicine.


Yesterday’s blog message was an introduction to PDA’s new Medicare Advantage offering. The special element in this product is medical management of the patient population.  A team made up of PCPs, PDA’s Medical Director, and actuarial engineers with cost accounting strives to manage quality care and excellent customer/patient service. This is accomplished for the same dollars that Medicare provides the “free style patients” that are on their own to figure out the current healthcare system. There are financial incentives are to motivate the PCP to put his arms around a specific population of patients and to use his medical skills and judgment to maximize their health.  The key to success is to provide effectiveness and efficiency of care in a measurable way.

The Texas Department of Insurance defines this product as an “HMO”.  The mention of “HMO” dredges up countless negative emotions in those who practiced medicine in the 1980’s and 90’s.  What we really have here today is a straightforward mechanism for converting your current Medicare patients into a better demographic profile.  In plain English, you’ll be paid more for the work you’re already doing.  You will simply invite your current Medicare patients to enroll (at no additional cost) for improved benefits and continued access to your office.  If you are caring
for Medicare patients, this is a very positive approach.  Then, if you find that the program suits you, additional patients can be added.

The first wave of organization is PCP-focused.  The second effort will relate to the PCP-specialist
referral patterns.  The physician credentialing process begins next week.  There is no time for PCPs to be concerned that they won’t be able to refer to their favorite specialists, or for specialists to worry that their referring PCPs won’t be in the network.  PDA will work this out together as a team, guys.  PCPs can spread the word to their specialist friends and vice versa.  Even better, PDA can take an active role in this process.  Simply give us the names of physicians you would like us to approach, and we’ll take care of the rest.  Time is very short.  Please contact the PDA office now to be included in this program.


PDA has been working non-stop to make good the commitment of more income with less hassle and no additional time demands.  Good spirit and hard work is starting to pay off.  PDA is finalizing a contract which will allow members to immediately begin upgrading their Medicare income.  The prospective new contract is with Universal American, the parent company for a Medicare Advantage plan.  This Medicare Advantage agreement will provide access to both (1) a medically managed HMO (“Texan Plus”) that has no downside risk and (2) a Preferred Provider Organization plan (“Today’s Options”).

Primary care physicians participating in the Texan Plus will receive the Medicare “reimbursement” they are accustomed to, as well as two entirely new sources of income:

1)      $8.00 per member per month (PMPM).  (Example: if you care for 100 Texan Plus patients, you are paid $2,400 per quarter whether or not any of those patients visit your office.)

2)      Gain Sharing.  (Efficient medical care will be rewarded with bonuses.)

It is called an “HMO”, but THERE IS NO DOWNSIDE RISK IN THIS CONTRACT.  It simply improves your Medicare income.  If the insurance company does not meet its performance goals, the PCP physicians will still receive their usual Medicare reimbursements plus $8.00 PMPM but no gain sharing.  The specialists will receive their regular Medicare reimbursement and a potential gain sharing bonus as well.

Texan Plus is presented in conjunction with an open access PPO called “Today’s Options”.  The PPO works like any other preferred provider contract, but reimbursement is at Medicare rates with PCPs receiving a 3% additional bump.

As mentioned, PCPs will reap immediate and significant rewards by encouraging their patients to convert from standard Medicare to Texan Plus.  This conversion is a win-win because the patients will receive a significant upgrade to benefits at no additional cost to them.  In addition, if a PCP wishes, Universal American and PDA will move additional patients his way through directed marketing efforts.  For additional information, please contact the PDA office.

ObamaCare Related Expense

An issue being dealt with at PDA since February of 2011 deserves a little attention in our blogs.  The American Recovery and Reinvestment Act of 2009 (“ARRA”) and the Health Information Technology for Economic and Clinical Health Act (“HITECH”) are a Pandora’s box of regulation and process.  Still, PDA must strive to stay current and represent the independent physicians’ best interest. Federal bulletins have indicated that there must be a special business associate agreement (“BAA”) between providers (the physicians) and their business associates (PDA) if HIPAA-protected confidential information is to be exchanged.  This BAA must include new clauses referred to as “HiTech 2010”.

In straight talk, that means if an office has a billing issue and wishes to share the data with PDA mission control, the physician’s office may need an enabling piece of paper before sharing data.  The IPA will be happy to provide the form if you don’t already have it.

Each physician joining PDA signs a membership agreement which declares that any state or federal laws not specifically addressed in the agreement will of course be honored.  And, it is PDA’s duty to make a best effort to stay in front of the physicians’ administrative challenges. Our physicians can continue to count on PDA being on-the-job.

The new language can be easily found on the web.  One excellent location for a form which can be appropriately modified is the TMLT:

Healthcare Quality

Dr. Daniel Karin, Medical Director of PDA, is a member of the American Institute for Healthcare Quality, and he is working toward board certification by the American Board of Quality Assurance and Utilization Review Physicians.  As such, he would like to bring their message to the readers of our blog.

Quote from the American Board of QA and UR Physicians:

“As health care evolves and we [the federal government and the nation] move closer to instituting elements of the Patient Protection and Affordable Care Act, questions and concerns are abounding.  The health care system is moving towards a team approach to health care, ensuring the quality, appropriateness, and cost while improving overall care to patients.

“We, as providers, employers, and especially as patients, are looking for reassurance, throughout the entire health care continuum, of continued and renewed dedication to improved care, through coordination and communication. 

 “Can we bridge the link between cost and quality?  Are we all prepared to be engaged in accountable, coordinated, responsible care?”

The answer to these questions is clearly: “No, not yet.”  Conceptually, we at PDA support this movement toward quality and efficiency.  These goals are lofty and challenging with a mission that is broad and obvious to all.  But at the same time, they must be coupled with making a financial return on the investment of becoming a physician.

PDA is moving rapidly and pragmatically in the right direction.  As we build our infrastructure and prepare to initiate our first community health plan, we have confidence that PDA will be leading the way for DFW physicians, and soon for physicians across Texas.

Your interaction and comments are valuable and appreciated.