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America's best medical society?


The Texas Medical Association may be just that. We took a look at what makes it so dang good.


America's best medical society?

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Choose article section...Flexing political muscle with stunning success Holding the commissioner's feet to the fire Appealing to the grassroots by taking on physician hassles Can the TMA formula be exported beyond Texas?

The Texas Medical Association may be just that. We took a look at what makes it so dang good.

By Wayne J. Guglielmo
Senior Editor

Thealene Graham of Austin, TX, was at her wits' end this spring. Despite repeated calls to Humana/Employers Health Insurance—a PPO that her 12-member medical group had contracted with—the reimbursement specialist still spent much of her day struggling to get claims paid at the agreed-upon rate.

Tired of her solo battle, Graham sought help. In late April, she contacted state regulators, along with the Austin-based Texas Medical Association. TMA responded first, taking the problem directly to Humana. Within two weeks, many of the group's past underpaid claims were reimbursed in full, along with interest. The situation improved steadily from that point. Asked what she'd do if the problem resurfaced, Graham is unequivocal: "I'd go back to the TMA in a heartbeat."

Rock-solid support among TMA faithful isn't uncommon. Indeed, frustrated by changes in health care, many Texas doctors and their office staffs view the organization as a white-hatted cowboy battling valiantly on their behalf.

In return, Texas doctors have rewarded the TMA with the kind of loyalty that's rare in organized medicine today. The TMA is not only the largest state medical society—with more than 37,000 members, including residents and medical students—but arguably the most powerful. "If you're on the other side of an issue from them, you're well advised to look for a compromise," says Neal T. "Buddy" Jones, an Austin-based lobbyist who represents Aetna US Healthcare, among other clients. "If you can't find one, be prepared for a long, hard battle."

Not every would-be foe has such grudging respect for the TMA. Nor does every Lone Star State doctor sing its praises. Still, as a grassroots advocate and in-your-face political force, the TMA may be without peer within organized medicine.

Does the TMA model offer lessons for doctors under siege in other states? We took a closer look to find out.

Flexing political muscle with stunning success

The modern TMA cut its teeth in the 1980s in a now-legendary feud with the state Supreme Court.

Back then, many Texas physicians believed that the top court's malpractice decisions were tilting disproportionately against them. Starting in 1987, TMA launched a multifront campaign to unseat what it viewed as plaintiff-friendly justices. By rallying the grassroots and backing doctor-friendly candidates (Texas justices are elected), the campaign succeeded beyond anyone's expectation. During this same period, the TMA joined forces with other groups to assure passage of some of the hardest-hitting tort reforms in a decade.

These battles "unified the leadership and all the county medical societies," says Fort Worth allergist Bob Lanier, immediate past president of Tarrant County Medical Society. They also made the TMA a force to be reckoned with.

In the years since, the TMA has flexed its political muscle with stunning success—pushing through measures in the areas of patient protection, HMO liability, and physician collective bargaining. It was also a key player in brokering a voluntary agreement between Aetna and the Texas attorney general that addressed a range of physician complaints.* Each in its way has been groundbreaking.

During the 2000 elections, TEXPAC, the TMA's political fund-raising arm, spent close to $1 million to support doctor-friendly candidates up and down the slate. More than 5,000 TMA physicians, contributing an average of $125 each, belong to TEXPAC, according to the latest count. Excluding the two major political parties, that makes TEXPAC the second largest political action committee in the state, behind one representing real estate agents. Despite some slippage in recent years, TEXPAC remains among the largest state medical society PACs in the country.

Holding the commissioner's feet to the fire

With the election behind it, the TMA turned its attention this year to other matters.

This spring, it joined state medical societies in California and Georgia in a federal suit against several HMOs for alleged abuses like late payments and denial of care. The suit, part of a group of similar actions now in US Federal District Court in Miami, has moved into the discovery phase. (In its complaint, the TMA named both Humana and Cigna. Aetna was excluded because of its voluntary efforts to work out differences with Texas doctors.)

Within the state, the TMA took a double-barreled approach to the issue of prompt pay by insurers: First, it lobbied Insurance Commissioner José Montemayor to do a better job of enforcing prompt-pay laws already on the books. Responding to a TMA invitation to visit county medical societies, Montemayor barnstormed the state.

He learned that insurers were routinely flouting the rules he'd issued only months before, and that Texas doctors were steaming. "There were places where a couple of hundred doctors and their staffs had come together, and it was really like an angry mob," says Kim Ross, TMA's charismatic vice president for public policy, who accompanied the commissioner on his tour.

Montemayor got the message. "I have to say in all fairness that the TMA had not misrepresented the situation," he says today. In April, Montemayor appointed an ombudsman to handle doctors' slow-pay complaints. He also posted a complaint form online, scheduled a series of prompt-pay workshops, and pledged to "tune up" department rules to improve compliance.

The second barrel of TMA's prompt-pay strategy involved the legislature. Instead of just adding teeth to rules issued under the existing statute, "we were going to give Commissioner Montemayor a bigger and better statute," says Ross.

The TMA had several tricks up its sleeve. First, plans would be required to give doctors a heads-up—a statement of their intentions—within 45 days of receiving a clean claim. Second, they would be required to pay 85 percent of any audited portions of a claim, rather than delay payment until the entire claim was audited. And third, they would be forbidden to maneuver around the required 45-day payment period by getting doctors to sign individual contracts, as many had done. These provisions were part of a more comprehensive bill then being considered by the legislature.

The HMO industry and business groups attacked the bill as costly and administratively impractical. Frosty relations between the Texas Association of Business & Chambers of Commerce and the TMA iced over when the group took out a newspaper ad attacking TMA for pushing a bad bill. (The group's president did not respond to repeated calls for an interview.)

On June 17, Gov. Rick Perry vetoed the TMA-backed legislation. But despite this last-minute defeat, the association had once again proven it could legislatively outmaneuver and outmuscle its opponents.

Appealing to the grassroots by taking on physician hassles

Big policy wins are only one part of the TMA story. "Everything is grounded on what's actually happening out there in all parts of the state and the grassroots," says Louis J. Goodman, who became executive vice president five years ago.

One way the TMA stays in touch is through the Hassle Factor Log. Established two decades ago, the log gives practicing physicians the chance to register—and even resolve—their beefs with insurers. Intake forms can be faxed or sent over the Internet. Not surprisingly, payment delays and claim denials have topped the hassle list recently.

Last year, TMA staff reviewed more than 5,000 complaints from physicians and their staffs—a 53 percent increase over the previous year, according to a year-end report. After screening complaints, the TMA helped more than 1,800 physician practices to resolve their problems. It also assisted doctors who contacted the association less formally.

Staffers use the log's database to track not only what's bugging doctors, but which carriers are responsible and in what regions. That in turn, say officials, helps shape and inform periodic meetings with plans and the Texas Department of Insurance, legislative initiatives, and even lawsuits. "In our suit against Humana and Cigna, we went back through the Hassle Factor Log and pulled out information relating to specific issues," says Teresa Devine, who oversees the log and other reimbursement-related programs.

The TMA stays close to its grassroots in other ways, too. In any given year, for example, it sponsors between 1,000 and 2,000 miniconsultations. These are a series of half-hour meetings, hosted by the county societies and free to members, in which doctors or their staffs get to pick the brains of TMA experts on coding and claims processing. The association also conducts up to 160 practice management workshops each year. And it works with large medical groups to resolve problems ranging from faulty claims processing to computer glitches.

It's hardly surprising that most doctors who belong to the TMA seem to see real value in their membership, despite the occasional gripe. "I don't think the TMA has been able to give doctors everything they want," says internist Bayard Paul Quinn of Texarkana, "but I still think it's the best organization we have."

Can the TMA formula be exported beyond Texas?

Can other states replicate the TMA's mix of practical assistance, grassroots advocacy, and political hardball?

Certainly, there are strong, committed medical societies beyond the Lone Star State—in California, Colorado, Georgia, Massachusetts, Oklahoma, and Rhode Island, for instance. And certainly, Texas benefits from the sheer number of physicians in the state. Still, observers note, the TMA does things that any medical society committed to physicians' causes would do well to learn from.

At the top of that list is the spirit of collaboration between state and county. "Counties touch members in ways the state can't," says Brian O. Foy, executive director of the Oklahoma State Medical Association. "The state provides services the counties don't have the resources to provide. Both are needed. Texas does it as well as any state."

Having the state and counties pulling in the same direction leads to big payoffs. Not only do individual physicians feel connected and empowered, but the TMA can speak for a solid majority on many major issues.

There are fault lines, of course. Some primary care doctors complain that the specialists—who outnumber them in the association by more than two to one—have too much power. And there are also the predictable schisms between individual physicians, large groups, and IPAs.

Despite this, the TMA more often than not presents a united front when approaching lawmakers or regulators. Couple this with real expertise and hard work—not to mention an insider's track in dealing with the Bush administration—and it's easy to see why the TMA is often viewed as a model. "I can't think of a medical society in this country that wouldn't want to replicate Texas," says Steven DeToy, director of government relations at the Rhode Island Medical Society.

Adds Fort Worth allergist Bob Lanier: "If the AMA were as good as the TMA, there would be a hell of a lot of changes going on inside of medicine."

*See "The Texas law: On target, or firing blanks?" Aug. 23, 1999, and "Collective bargaining for doctors: What the Texas-Aetna agreement really means," Sept. 4, 2000.

Wayne Guglielmo. America’s best medical society?. Medical Economics 2001;15:77.

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