Preparing your healthcare organization for value-based care

Baker Tilly presents a value-based care readiness series to help your healthcare organization be better prepared for the paradigm shift to value-based care.


“Pay for Performance”

An outstanding nurse practitioner and physician assistant cadre is growing, adding to PDA’s capability to perform successfully in the new environment

The escalating shortage of primary care physicians has led IPA management to consider the emerging roles of nurse practitioners (NPs) to improve access to primary healthcare services. Since 1996, there has been a steady increase in the number of NPs. That trend, along with the enactment of state laws to expand the scope of practice, prescriptive authority, third-party reimbursement and national efforts to improve healthcare access, has resulted in dramatically expanded roles for NPs in providing primary care services.

PDA has respectfully and conservatively evolved policy and IPA procedures over its lifetime. Today, PDA offers Nurse Practitioners an opportunity characterized by equality, with hospital-owned practices and other employment roles. PDA welcomes the energy and vision of all licensed healthcare providers who are seeking an IPA that provides credentialing and verification by contracted managed care companies.

The changing state of care delivery systems, value-based provider delivery models (PODs) and consumer demand have led PDA to credential and represent medical professionals such as physician assistants, nurse practitioners, nurse anesthetists, psychiatric and psychological clinicians and therapists, physical therapists, and speech therapists. As PDA supports integrated delivery in coordination with managed care, these medical and clinical services represent a growing number of current and future dues-paying members of the organization. Their decision is sound, allowing PDA to represent their services in contrast to the unstructured, contract-by-contract selection process and spot market compensation by managed care. They will be treated with equality regarding dues, contract opt-in, policy, procedure and opportunity to serve on the Board and/or Committees.

PDA has proven to be resilient and creative in representing members as the managed care market has evolved. These changes have been subtle and effective because they exactly track with the managed care market for funding healthcare, the inpatient and outpatient segments, and a diverse provider universe.







6 things doctors need to know about the MACRA final rule

By Todd Shryock, Medical Economics
October 14, 2016

The Centers for Medicare & Medicaid Services (CMS) released its final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) on October 14. Here’s what physicians need to know…

6. Who has to participate in MACRA? If you bill Medicare more than $30,000 annually or provide care for more than 100 Medicare patients each year, you are affected by MACRA. If you do not meet those benchmarks, you are exempt from its requirements.

5. When does MACRA take effect? The program begins Jan. 1, 2017, but if you are not ready by then, you can choose to start collecting performance data as late as Oct. 2, 2017. Whenever you start, performance data is due by March 31, 2018.

4. Why are there different starting dates? To make it easier for practices to comply with MACRA, CMS created four options, each with its own requirements.

  • Option 1: Test the quality payment program. As long as you submit some data—for example, one quality measure or one improvement activity—you can avoid a downward payment adjustment. You need to start collecting data no later than Oct. 2, 2017.
  • Option 2: Participate for part of the year. If you submit 90 days of 2017 data to Medicare, you may earn a neutral or small payment adjustment. You must start no later than Oct. 2, 2017.
  • Option 3: Participate for the full year. If you submit a full year of 2017 data to Medicare, you may earn a moderate positive payment adjustment. You must start collecting data Jan. 1, 2017.
  • Option 4: Participate in an Advanced Alternative Payment Models in 2017. Instead of reporting quality data and other information, the law allows physicians to join an Advanced Alternative Payment Model, such as a Medical Home Model. This can result in a 5% incentive payment in 2019.

Regardless of which option you choose, to earn the possible positive payment adjustment that starts Jan. 1, 2019, all 2017 data must be submitted by March 31, 2018.

3. What happens if I ignore MACRA? If you don’t send in any data, you will receive a negative 4% payment adjustment in 2019. This penalty increases each year thereafter: 5% in 2020, 7% in 2021 and 9% in 2022.

2. Is this the last of the changes to MACRA? No. CMS indicated it will continue to listen to feedback and adjust rules as necessary and is already working on additional APM options to get more physicians involved.

1.  Is there any help available to help me with implementation? The Transforming Clinical Practices Initiative (TCPI) program offers assistance to transform your practice. Clink on the following link to find organizations in your area that can help:

Message From The PDA Benefits Desk

Some small companies driven by a tightening labor market and rising costs and fewer choices for individual coverage are reversing the practice of providing no health insurance. Workers are looking for healthcare. Job candidates are seeking employment that offers health benefits. That fact is also driven by major carriers ceasing to offer individual coverage. Individual policies seemed like a good option when the Affordable Care Act took effect. But, group plans have more value now.

Unlike large employers, small businesses –those with the equivalent of fewer than 50 full-time employees– aren’t required to offer health benefits under the ACA. Many do so anyway to remain competitive in the job market or because they think it’s the right thing to do.

The world for small businesses is quite dynamic. Companies in the current small group market are also accepting that benefit plan financial contribution is a creative variable. For example, 50 percent of premium cost can be a positive position for a less-than-50 full-time employee group. Also, the small group self-insured market, when joined with wellness and population health services, is an attractive cost-benefit option.

Questions about the merits of individual-versus-group coverage are intensifying as changes continue to roil the insurance market.  There are two sides to this issue. Agencies that work with small businesses across the country say most small businesses making changes continue to shift to individual coverage because their workers are eligible for significant government subsidies. But the trajectory of that is slowing, as there is a reverse migration back from individual to group.

Timely Statistics and Facts

Conflicting forces are buffeting small companies. Transitional rules that allowed certain companies to continue offering existing plans that don’t meet certain ACA requirements expire at the end of 2017. In North Carolina, some companies could face cost increases of as much as 40 percent for ACA-compliant plans.

At the same time, prices for individual coverage are climbing and insurance companies are dropping out of the state and federal marketplaces that sell individual coverage. Last week, Aetna Inc. said it would withdraw from 11 of the 15 state exchanges on which it currently offers coverage, making it the latest major insurer to pull back from that business. Estimates of how many small businesses offer group coverage vary. 54 percent of companies with three to 49 workers offered health benefits last year, about the same as in 2014 but down from 66 percent in 2000, according to a 2015 Kaiser Family Foundation survey.

Companies with three to 50 employees paid an average of $15,602 annually for each worker who elects family coverage, according to Kaiser, up from an average of $12,809 in 2010. Government subsidies can make individual coverage attractive to small firms employing workers earning as much as four times the poverty rate. For 2016, the ceiling generally was $97,200 for a family of four. Employers, however, generally can deduct the cost of group healthcare premiums.

Before the ACA, insurers often denied coverage to individuals with existing conditions; one reason costs were often higher for small groups. But the price gap has narrowed significantly. Individual coverage, meanwhile, has grown less attractive as insurers narrow options for physicians, hospitals and prescription drugs in an effort to cut costs.  There are also a lot of bad surprises, like showing up at a hospital with a doctor and being out of network. Finding affordable coverage is hard. The Broker/Agent is an invaluable asset, if educated with facts and aggressive in working with the market.

Sources: Wall Street Journal, CNBC and other wire reports.

An MSO Announcement

The Management Services Organization that leads Physicians Direct Access (PDA) IPA is proud to announce the inculcation of PDA within the Scott & White Health Plan (SWHP) network. It is great that we are contracted with this growing network!

This major achievement began in January with meetings including the senior marketing and network operations executives of SWHP and the insurance sales agency of The Miers Group and the MSO serving PDA. The plan was to both produce meaningful benefits plan sales for the new SWHP product and also to be a mobile, in-touch provider network component for SWHP. The network component intends to coordinate with SWHP merger and acquisition needs and practitioner network completeness. It was understood that PDA will make every effort will be to coordinate and support perfection of the narrow network product. The MSO recognizes the importance of educating PDA providers to grasp the concepts of a narrow network as preparation for “pay-for-performance” is underway. Our agency component has similar challenges with presentation and education of narrow network benefits to prospective and existing customers.

It is intended that the PDA physicians participating in SWHP will begin loading into their IT system after the first of September. As this is completed, the MSO will communicate closure to the participating PDA practitioners. Also, narrow network rules and regulations, etc., will be an ongoing IPA education effort. The PDA group will have delegated credentialing privileges and the ability to add new practitioners to SWHP as is appropriate. That is a major achievement in speed of operation.

Currently, the IPA is recruiting members from new community areas containing independent practitioners. For an example, the Walnut Hill Hospital medical staff is being introduced to PDA and the new and existing 2016 managed care portfolio. This is an exciting opportunity to build new relationships.

There will be delays and administration stoppages, but PDA, your IPA, is a growing business with one of the most important patient distribution systems of North Texas. It is believed that with Aetna, Blue Cross, Humana, SWHP, United, Universal American, etc., and all the creative self-insurance plans being sold are seeking an IPA that “Gets It!” and that is the MSO’s mission.

PDA is preparing for “Pay For Performance” and “Population Health Management”.

Looking Back: A Maturing Healthcare Message

For many years, DFW independent physicians have had a weekly dialogue and briefing point with Buddy Miers. The first message was the “Monday Morning FAX” which greeted the JVE physicians in 1987 as managed care arrived in Dallas. 1,000 physicians waited every Monday for an update on what was up in the developing managed care world.

After eight years, the message moved to Southwest Physician Associates (SPA). The audience also evolved as SPA was focused on “risk-reward” contracting. It was the 1990s and the time of HMO contracting. It was also the period of physicians being purchased and PCPs beginning to drive the bottom line of medicine. The message then moved to a broader southwestern scope as a new podium was created with an exciting Nurse Practitioner and Physician Assistant start-up company. That message also embraced the long-term care continuum, from PCP-led home care, assisted living, skilled nursing, to LTACs. After an acquisition, the message then moved to a cutting-edge “hospitalist” venture. But, the Monday morning messages remained a dependable resource that was followed by many practitioners across the state and beyond. Often the message had to be physician-penned, but the communication was never stilled.

In 2004, after an incredible year of hospitalist development and chronic disease clinic operation, Buddy Miers returned home with a mission to build a healthcare ecosystem. The founding team was a corporate benefits marketer, two CPAs (one corporate, the other in public practice), three wonderful physicians who had the grit to obtain their benefits consulting and general insurance licenses, a hospital-ancillary executive with public company experience, and a business generalist. Another key ecosystem piece was needed, so a general IPA was identified and placed into the ecosystem structure. Since then, the brands Flagship Network, The Miers Group Benefits, Physician Ventures, PDA of Texas, IPA, etc. have been secured and linked to the LLC’s managing unit.

Now, with the shock of Obamacare somewhat processed, merging of delivery systems and insurers, the ecosystem prospers and has no outside debt. It is just beginning to listen to investment requests for growth capital.

The dark days are passing. Federalizing healthcare and concentration of managed care bargaining power is becoming accepted and understood. The Ecosystem is optimistic and sure that there will always be independent practitioners to serve. And, the ecosystem will be ready to serve their needs with integrity, grit and hard work.

Almost 1.6 million people dropped out of Obamacare this year

News Flash: Almost 1.6 million people dropped out of Obamacare this year 20160701

The EMR Conundrum

The enigma surrounding the pilgrimage of acquiring & adapting to a medical EMR is daunting. Bottom line is the MSO and PDA/IPA totally accept the need for an interactive, productivity enhancing EMR. The fact is many physicians are dragging their feet in committing to an EMR. They have good reason for hesitation. The major issues of EMR expense and ease of use continue to be hindering factors to adaption. Plus, the all important sense of confidence with the everyday adaptation is a significant concern. Hardware and system costs are just part of the expense issue while training, balky data exchange, etc. are irritating provider and staff issues.

Issues also must correlate with the appropriate expectation of a material addition of profitable new business. New revenues have to accompany and fund an anticipated EMR purchase and adaptation. Add in the governmental threat of a high-dollar charge to go with not meeting CMS performance expectations. Those CMS-promised penalties for poor performance may encourage physician dropouts. These are major MSO concerns at the mid-point of the 2016 business year.

The MSO wants to pursue pay-for-performance. The price for a PDA-sponsored EMR could be $50,000 ±. The commonplace issues, compliance liability, and fully costed implementation are serious in their own right. But, a successful EMR must have clinical and data exchange with financial integration. This has to be done. Failure is going to result in fines, benefit plan push back, and practitioner dropout from CMS. The MSO management is working overtime to figure how to approach this puzzling, complex, and potentially destructive issue.

Your insight and experience is solicited. It is now time to fully engage this issue. The Physician Organized Delivery (POD) model is on the drawing board for PDA. The major hospital CIO model remains a challenge. ACO options are numerous. This is the bridge to be passed to reach the upside revenues of pay-for-performance. And, it must be done in a manner that saves the existing at-risk primary care cadre.

The IPA also needs to coordinate with benefit sales to commercial and governmental insurance. That is essential to survive in the new oncoming paradigm.

Healthcare’s Attendant Costs

A friend of the IPA faces the challenge of a cancer diagnosis. He has decided to deal with that situation with the help of M.D. Anderson in Houston, Texas. He is a strong, brave person who is up for a fight and we wish him all the best.

In discussing his insurance benefits with us, he has told us that it is the “surprises” that get him down. For example, the chemo medicines have surprises. But, so do the incredible freeways of “H Town”, van rides from the airport to the Houston Medical Center, and so many other new experiences that amount to “surprises”. Undoubtedly, traveling to a treatment site in another city or just across town has a lot of surprises and new experiences to master.

Patients often complain about one other very serious surprise. When one has health insurance and major medical, there is also a degree of anticipated mental preparation to face the financial costs of cancer. But, no one ever thinks about the costs that occur because of the trips, hotels, meals, childcare, and other miscellaneous. Such expenses are very real and they do add up to expense not easily planned for and often unavoidable.

There is indemnity type insurance for these expenses, but few “buy/purchase” the peace and security provided by ancillary coverage. Simply put, an example of this type of coverage is an ancillary plan that pays a fixed amount on the first day of a cancer diagnosis. This type of insurance can save the family great heartache and goes a long way to protect the patient’s credit status. Such coverage should be tailored with the employee benefit plan.

I have developed a relationship with professionals that represent this type of product and the skill to place it. I am going to ask them to call on the MSO workers that serve PDA. And, I hope they will knock on your door and ask if you would like to see how this coverage works. And, you will be impressed by the financial value vs cost in relationship to major medical insurance.

The general ancillary plans are disability, accident, life, cancer, critical illness and other interesting options. The lead professional that understands this product is Georgina Milum. Her phone number is 214-755-7518. Think these niche solutions over as presented by Georgina and her staff. She will share both her technical expertise and a gift of empathy that few possess.

Follow-Up Message on MSO Opportunities

This is an exciting time for Physician Direct Access (PDA). The IPA is privileged to have each workstation filled with a bright, motivated college intern.

Starting today, a four-person team will be working on real world challenges for your IPA, at the same time gaining wonderful practical experience. Quickly, here is what they will start the day with: necessary work in the malpractice quoting area, pursuit of reimbursement issues with the help of the IPA Administrator, scanning documents into our database, general compliance training and HIPAA instruction that enables a higher level of service, and pulling input for Tuesday’s operations review with Dr. Dwight Lee, Chairman and Medical Director of PDA.

A fifth person will be totally engaged in recruiting and fieldwork. This area can still add another intern if you have a child or referral for PDA’s summer internship. The positions have filled up in amazing order.

We now have our program paired with area universities that encourage internships with firms like ours.

We are delighted when a past-intern achieves current tasks and then moves up to a new, more-difficult level of challenge. For example, Shawn Adams, son of Dr. Stuart Peake, has been selected and awarded a grant to attend a fifth year of Graduate finance training by the renown Washington University of St. Louis, Missouri. We intend to be waiting for him upon completion of his MS degree.

Good things are happening here that translate to profitable growth in the complex ecosystem of benefits, managed care, and service delivery.