The Texas Medical Association may be just that. We took a look
at what makes it so dang good.
Aug. 6, 2001
By Wayne J. Guglielmo
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
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
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
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
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
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
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
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
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
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,
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
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
Copyright © 2001 and published by Medical Economics Company at
Montvale, NJ 07645-1742. All rights reserved.
Copyright (c) 2001 by Medical Economics.
Reprinted by permission from Medical Economics magazine.
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