Ramping Up Selling Our Physicians Capability

Here is a big, simple fact! The Flagship Physician Network is now your sales agent for consumer direct contracting. This is the new self-insured product that is sold straight to the 10 life to 250 size worker groups. That market segment is the homeland niche of the beleaguered small business owner and operator. And, that is where the independent practitioner has to stand tall and victorious in seizing commercial market share. Why? Because there is no better avenue to reach and secure reasonable compensation for the PDA/IPA Physician. Great, that leads us to a closer focus on what are we selling? Or, what would you say if you were treating a patient…that was a business owner or operator, and the topic of the current ObamaCare issues and the uncertain economy worked into the discussion?

That is where an “ELEVATOR PITCH” is really helpful. You need an understandable answer that can be said in the time it takes an elevator to reach the top floor. You might say……….

“It is my pleasure to share that self-insured employee benefits are now available to companies that employ as few as ten workers. This brings you a powerful tool once only available to big corporate America! Today, your benefit plan can be managed as a line-item monthly cost that is variable versus actual expenses… while you are being protected on the high side by stop-loss coverage. “

“With our Flagship plan, you will always have an unchanging monthly premium. I am saying…that is the same $$$ cost every month. But, should expenses be less than planned, the unspent dollars fall to your bottom line. Again, If unfortunate expenses actually exceed the premium, there is stop-loss coverage that clicks in for both individual and aggregate needs. We have developed a plan that is built upon local physicians and hospitals. We also cover employee needs if they need medical care while out beyond the local market. May I have one of our Texas Department of Insurance licensed physicians or a team broker tell you more about the features and benefits of the Flagship Physician Network?”

The elevator pitches can vary with the sales environment, relationship, or place-in-time. But, this is so exciting! Now we can move out to make you more money without adding bureaucracy or urging you to work harder. This is a community based, low-overhead patient pipeline. Call us or answer this message with a request for a face-to-face. More support is coming!

Performance Metrics


This is a timely message regarding Medicare Advantage contracting. PDA/IPA has focused contracting and performance on one Medicare Advantage agreement with Universal American (UAM). This provider was selected by PDA to concentrate organizational focus on a single such program. This is agreement led to certain favorable contracting terms and conditions of training relating to medical management. As the IPA supports the build-out of the Flagship Physician Network, a self-funded small group benefit plan, the acquisition of medical management expertise is essential for success. 

The future of medical service delivery by independent practitioners will undoubtedly hinge largely on the self-control of patient care and meaningful use of care information along appropriate pathways of care. Dr. Karin, the Medical Director of the Flagship Physician Network has sought training from UAM and other sources. He is both a Board Member and the leaders of the utilization and quality function for the IPA. 2013 progress is measurable, profitable, and yet the ultimate destination is distant. Again, this is the key to future success for our collegial efforts.

We are driven to educate our terrific “rank & file” practitioners about the Flagship product. However, there is an interrelated challenge to instruct primary care on the various types of measures of upcoming bonus incentives and the criteria for earning the rewards. This does not apply to any existing contracts. This is the way of the future:

1.      Stars Bonus

2.      HEDIS Bonus

3.      Health Assessment tools


More to come. Next discussion is to spell out and discuss these avenues of measure performance.

How does Per-Employee-Per-Month (PEPM) Relate to What a Physician Is Paid?

Focus with Physicians Direct Access, your IPA, on how commercial insurance pays you as a practitioner. Let us begin with BUCHA (Blues, United, Cigna, Humana, Aetna, etc.) and their annual determination of the payment for an office visit. Through a twisting pathway, the payment is ultimately determined and plugged into a charge master (pricing list) that represents all specialties, facilities, etc. The physicians can see patients and bill as they wish.  But, the re-pricing of the claim will pay the contracted amount less co-pays regardless of the physician’s bill.

Now, if a company in the community is considering a self-insured healthcare benefits option, there is undoubtedly going to be a financial comparison between the BUCHA services and the Flagship Physician Network (FPN). That comparison is going to be over the entire range of services and pricing. Imbedded in that analysis is the comparison between the FPN value versus the BUCHA network and panel of caregivers. Insurers typically use a per-employee or per-member-per-month value to determine the cost and rate for group health insurance programs. The total funding generated by the PEPM creates the pool of money used to compensate physicians, hospitals, outpatient facilities, and all other aspects of medical providers. Example:  Individual and workforce actuarial rating and health reviews (could include pre-contract biometrics and employee interviews) for a 54 employee company:

41 workers in “Employee Only” class:  Monthly PEPM $465.47 generates $19,084.27 in premiums monthly

5 workers in “Employee & Spouse” class:  Monthly PEPM $1,019.35 generates $5,096.75 in premiums monthly

5 workers in “Employee & One Child” class:  Monthly PEPM $865.74 generates $4,328.70 in premiums monthly

3 workers in “Family” class:   Monthly PEPM $1,414.98 generates $4,244.94 in premiums monthly.

Total of 54 Employees generate $32,754.66 total monthly premium.

Monthly group premium in this self–insured PEPM model is $32,755. And, that expense covers medical claims, specific stop-loss, and aggregate stop-loss re-insurance. Generally, the comparison with BUCHA is very positive and compelling.  In a fully insured program, these premiums are paid to an insurance company.  The premium structure is designed, with the help of actuaries, to create a profit for the insurance company.  In an ERISA-based self-funded benefits package, the employer retains “unused” premiums and can refund the employees, reduce next year’s premium, or use the funds however he wishes.  ObamaCare forces plans to include benefits in a one-size-fits-all manner that practically guarantees surplus premiums for the insurance company because the premiums will cover unnecessary services. This can be avoided by switching to a self-funded benefits package where the employer is technically the insurer who keeps the excess premiums.  And, the employer can use stop-loss reinsurance to guarantee that his financial risk is no greater than it would be with a fully-insured BUCHA plan.

The next message from PDA will continue this explanation of self-insured benefits as a window of practitioner opportunity.

The Flagship Physician Network and PEPM

The main theme of the 2014 Blog series is how the Flagship product works and what is incorporated in the program for advancement of your interests.  As independent physicians, the PDA/IPA membership is seeking such answers regarding how to make more money, avoid hassle, and not have to work longer hours.

The IPA leadership maintains that being a stakeholder in the Flagship Physician Network (FPN) is crucial to achieving that goal. There is a major difference between a stakeholder product and one that views the practitioner as no more than direct labor. Here is the friction:  if Physicians are just direct labor and are only productive cogs in the big wheel of patient care, the PDA core objective of more income and less hassle is irrelevant. The PDA difference is that physicians have to improve outcomes and productivity, with an understandable, transparent and attainable potential for equitable new rewards, i.e., “Do better and get a piece of the action.”

Everyone is for that! Where do we begin? It starts with the coin of the realm, bitcoin, double eagle gold coins, etc. which is paying for healthcare in “PER-EMPLOYEE-PER-MONTH” units,  or in an abbreviated form…PEPM. This stands for dollars allocated to pay for healthcare in the context of “per-an employee-on a monthly basis”. This is actuarially developed usually in a manner that is adjusted for age, sex, chronic disease, etc.  For example, an insurance company may decide that a population of workers in the service of an employer in a specific industry with a definite history/pattern of claims may be insurable for “X# $PEPM”. That is a rough-cut example but it gets the idea over that insurance companies routinely decide what the PEPM should be and allocates their budgeted PEPM out to hospitals, physicians, etc. Then, this financial and statistical conglomeration manifests into a master contract that seeps down to the IPA level. The IPA usually can do nothing to change the PEPM. PDA is legally limited to serving as the credentialing and administrative messenger for their member physicians. This sets up a time when the IPA member physician is told that a proposed managed care agreement pays Medicare plus five percent for each contract approved CPT code. The message is that this is all based on the PEPM factor.

It does not take a rocket scientist to grasp that PDA must get to the place where it can control and/or influence the PEPM! The FPN and clinical integration offers such potential. That is so important! The FPN is a proprietary product that is based on PDA practitioners. The Medical Director is a PDA Board Member. The FPN market spokesman is the Chairman of the IPA. There are physicians who are seeking licenses to market the product to their friends and patients that own and operate businesses. The FPN and PDA have a significant shared potential. And, that future will be linked to understanding PEPM.

The next message will speak to re-insurance, i.e., stop-loss.