PDA and the “Opt-In” Process

Physicians Direct Access (PDA) values its role as the independent physician’s representative. As a messenger model IPA, PDA provides delegated credentialing services and receives contracts from various managed-care plans. As the conduit for managed care plans, PDA evaluates the overall offering, the financial stability of the host plan, and the potential for channeling patients to the care of PDA’s provider membership.

The IPA does not directly negotiate terms and conditions of the respective contract but seeks to facilitate the managed care company’s understanding of potential of member physician acceptance and participation. PDA also works to explain the content and practice value of the managed-care plan to the physicians. The IPA is truly a courier between the managed-care plan and the individual physicians. It is important that the IPA deliver a coherent and factual representation of the plan that is being messengered to the IPA membership.

The Physicians’ Response to an “Opt-In” Opportunity

Physicians shall independently determine whether he/she will participate or not participate in an individual healthcare contract offered by a third-party payor. Physician agrees upon PDA’s delivery of a healthcare contract to either accept or reject this opportunity within 30 calendar days following such delivery, unless a modified time frame is required. In the event that PDA does not receive the physician’s acceptance or rejection within such time period, physician shall be deemed not to have accepted the healthcare contract and will be “opted out” of the healthcare contract.

After deciding to accept a messenger-conveyed plan, the physician and office staff is invited to review materials and speak to the PDA office about the plan’s function, reimbursement and/or potential for new patient volume.

There is the possibility of a new major contract to be presented for membership consideration. PDA will advise as soon as possible.

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PDA and the Tenet CIO


Is Committed to Actively Participating in the Tenet Healthcare Corporation (THC) Sponsored and Physician Governed Clinically Integrated Organization(CIO)

The PDA service focus of delivering messenger model managed care contracts and contract-by-contract credentialing is a valuable, and absolutely necessary utility for the independent physician. That is a fact.

If a physician declines the out-right purchase of their practice, the existing managed care system practically requires the membership in a dependable, independent IPA. And, PDA is as good as it gets in providing these services at a minimal not-for-profit based charge. However, it must be noted that the oligopoly of the remaining large insurers, which provide managed care agreements to all IPAs, are ratcheting down base-line reimbursement for services. This is believed to be a long-term process with the downward drift gravitationally controlled by the baseline of Medicare reimbursement. Accepting that negative marketplace shift, PDA and the independent practitioner must find new sources of income to both replenish revenues and increase the operating margin of a medical practice. There is new promise that such new action plans can be achieved. PDA is aggressively seeking new revenue avenues today. These strategies also are totally without additional bureaucracy or more demands for practitioner time at work.

The PDA Chairman and the Board have instructed the Management Services Organization (MSO), i.e., the management component for the IPA, to aggressively pursue Tenet Healthcare’s invitation to participate in the CIO ramp-up. This makes sense as a significant number of our members are currently associated with THC hospitals. Plus, the original PDA was sponsored by National Medical Enterprises which is now THC. This is a positive second step after our initial success with a type of CIO in partnership with a Medicare Advantage plan.

PDA does not grasp as much as it will regarding the inner workings and financials of this plan. But, that will change. It is clear that PDA’s interpretation of the CIO mission is to progress beyond the traditional physician-hospital organization (PHO). The new goal includes building an active and ongoing program to evaluate and modify practice patterns by physician participants in conjunction with the hospital and outpatient resources. The desired result is to create a high degree of interdependence and cooperation among the physicians and hospitals in order to control costs and ensure quality of outcomes and incomes, PDA’s MSO will bring its extensive experience to bear in this arena, but still recognizes there is a lot to learn about this new model.

PDA is a Player in the THC Clinically Integrated Organization

PDA, the independent physician’s IPA of choice, has much to share with its membership, potential investors, and colleagues. Remember some things from PDA’s two decade past. From when National Medical Enterprises, Inc. (NME), the precursor to Tenet Healthcare, enabled the creation of an IPA around Trinity Hospital, RHD, etc., to engage in direct contracting with commercial accounts, the IPA was launched. Fast forward to today, in this age of the federalized Patient Protection and Affordable Care Act (PPACA), PDA has survived, improved service, and continued as a source for credentialing, claims advice, and messenger model managed care access. The original purpose and organizational expense, led by NME and later Tenet Healthcare along with a small group of designated physicians, is believed to not have resulted in a single direct contract. But, the IPA somehow did evolve successfully to where it is today.

PDA is a haven for the physician who seeks the security of independence and the upside of self-determined decisions. PDA has also evolved as an internally stable and financially workable not-for-profit entity. It has also recently contracted with a management services organization (MSO) that functions as a for-profit corporation and is aggressively seeking new partnerships and means of raising venture capital. These actions may provide PDA with new options and support in the near future.

A driver in this new age is that hospitals need independent practitioner support and participation in delivery systems that provide patient clients with cost efficient, higher quality care. Hospital employed physicians will also definitely be a core group contributing to that goal. But, PDA’s independents are another viable source of important care-giving productivity. Think about that fact. It is part of a changing IPA mind-set.

Last week a commitment was reached to work cooperatively with Tenet’s (THC) owned entity that is dedicated to distributing a clinically integrated product (CIO). PDA will learn, lead, and contribute from this new initiative. But, within the context of the agreement, the option is clearly open to pursue other PDA strategies and action plans without any non-compete or other inappropriate restrictions.

PDA will work hard to make this new relationship successful. The IPA Board has a genuine commitment to build trust and profitability with the new contracting effort. There is little to be paranoid about in this THC program because behind all the contract terms and conditions, the practitioners are the ones who do the work and they will respond only to fairness and meaningful goals. A PCP who has twenty-five plus patients to see tomorrow, is not one to be told “you have to do anything”. Does not work that way. So, positive cooperation is being pursued. And, more details will be forthcoming. 2015 is going to be interesting and a better year for the independent physician, nurse practitioner, physician assistant, designated provider of services, certified nurse assistants, office managers, etc.