December 2012 Dallas Medical Journal

I n t h i s i s s u e :

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submit letters to the editor to [email protected]

About the Cover Photo

The Texas Health & Human Services Commission is implementing the Texas Healthcare Transformation and Quality Improvement Program — a 5-year Section 1115 Medicaid Waiver. The Waiver is designed to improve access to health care, the quality of care, and to contain costs.

227 President’s Page Quality Care through Science, Education and Advocacy

231 Join the “White Coat Invasion” First Tuesdays at the Capitol

232 Large Group Practices 100-percent membership

235 Social Media Social Media Matters

236 Member Roundup Photos

239 President’s Page: Feature Article B as in Billions

245 A Conversation with Congressman Michael Burgess, MD

248 Parkland Foundation Celebrates Generosity of Medical Community

Dallas County Medical SocietyPO Box 4680, Dallas, TX 75208-0680Phone: 214-948-3622, FAX: 214-946-5805www.dallas-cms.orgEmail: [email protected]

DCMS Communications CommitteeRoger S. Khetan, MD ............................................. ChairRobert Beard, MD Gene Beisert, MDSuzanne Corrigan, MDSeemal R. Desai, MDDaniel Goodenberger, MD Gordon Green, MD Steven R. Hays, MDC. Turner Lewis III, MDDavid Scott Miller, MD

DCMS Board of DirectorsRichard W. Snyder II, MD ................................. PresidentCynthia Sherry, MD .................................President-ElectJeffrey E. Janis, MD .........................Secretary/TreasurerShelton G. Hopkins, MD ......... Immediate Past PresidentMark A. Casanova, MDWendy Chung, MDR. Garret Cynar, MDSarah L. Helfand, MDMichael R. Hicks, MDRainer A. Khetan, MDTodd A. Pollock, MDKim Rice, MDChristian Royer, MD

DCMS StaffMichael J. Darrouzet .................. Chief Executive OfficerLauren N. Cowling ............................... Managing EditorMary Katherine Allen ..........................Advertising Sales

Articles represent the opinions of the authors and do not necessarily reflect the official policy of the Dallas County Medical Society or the institution with which the author is affiliated. Advertisements do not imply sponsorship by or endorsement of DCMS. ©2012 DCMS

According to Tex. Gov’t. Code Ann. §305.027, all articles in Dallas Medical Journal that mention DCMS’ stance on state legislation are defined as “legislative advertising.” The law requires disclosure of the name and address of the person who contracts with the printer to publish leg-islative advertising in the DMJ: Michael J. Darrouzet, Ex-ecutive Vice President/CEO, DCMS, PO Box 4680, Dallas, TX 75208-0680.

Dallas Medical Journal(ISSN 0011-586X) is published monthly by the Dallas County Medical Society, 140 E. 12th St, Dallas, TX 75203.

Subscription rates$12 per year for members; $36, nonmembers; $50, overseas. Periodicals postage paid at Dallas, TX 75260.

PostmasterSend address changes to:Dallas Medical Journal, PO Box 4680 Dallas, TX 75208-0680.

Richard E. Anderson, MD, FACPChairman and CEO, The Doctors Company

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President’s Page

Richard W. Snyder II, MD

Richard E. Anderson, MD, FACPChairman and CEO, The Doctors Company

We reward loyalty. We applaud

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As the end of the year approaches, I am submitting my last article as president of

the Dallas County Medical Society for the Dallas Medical Journal. I am sure that for some there is a sense of relief that I have written the last of my obnoxiously long President’s Pages. I suppose it also is true that Lauren and Tracy at DCMS are heartened knowing that they will have more free time because they won’t be devoting hours upon hours to my obsessively endless rewrites. There probably will be fewer trees sacrificed and less computer memory occupied. Sorry, gang, but you inspired me; at times I just could not help myself!

To my surprise, I have found that serving DCMS as president has been the most rewarding aspect of my career as a physician. I am not making that statement lightly! Little did I suspect before the year began what an impact the society could make in the lives of the residents of Dallas County. The spotlight on our vision statement “to promote a healthy community” has never been brighter. And I think you’ll agree that through our involvement with West Nile virus, the 1115 Waiver and Medicaid expansion, the evolution of the North Texas HIE, and our support of Parkland, our DCMS mission statement “to advocate for physicians and patients” is being fulfilled. Our successes are breathtaking.

But we are successful only because we, the physicians, get to work daily with those crazy characters at the society — particularly Michael, Connie, Tracy, Deanna, and Lauren (sounds like a reincarnation of the Mickey Mouse Club). Before serving as president, I never knew what a talented, energized and devoted crew we have working for us at DCMS. Their dedication to the society is unparalleled with 10-, 15- and 20-year employment anniversaries the norm. This is even more impressive when you consider how much more their talents are valued monetarily at other locales, yet they choose to sacrifice, giving of themselves to serve the Dallas community through the society. They are my inspiration.

I also have been galvanized by working with such incredibly engaged physicians at DCMS who serve as my model for exceptionalism in physician a d v o c a c y . D e d i c a t e d doctors such as Shelton Hopkins, Cynthia Sherry and Jeff Janis epitomize that need in all of us to serve and give back to the

medical community. John Carlo, Wendy Chung, Bob Haley, and Jim Luby, you are my heroes for your contributions to mitigate the West Nile virus crisis. Because of your efforts, lives were saved, scores of patients were spared the horrors of brain damage, and some grandparents will get to know their grandkids. Jim Walton represents a beacon of hope, championing innovative pathways to healthcare access for the 30 percent who are uninsured in our county. Still, other physicians work dependably and relentlessly every day in the trenches of healthcare legislation. Lisa Swanson, Lee Ann Pearse and Bob Gunby are a few of the physicians pushing all of us toward excellence in legislative advocacy.

Simply the Best The combination of the DCMS staff and the

physicians makes a formidable team. No county medical society in the state of Texas, let alone the country, tackles as many complex and intricate projects as does ours, and with as much alacrity and skill. No other county medical society would have dared interject itself into the politics of the West Nile virus crisis, triggering a successful collaboration and intervention with the county, resulting in the saving of an incalculable number of citizens from permanent neurological impairment and worse. To quote Dallas County Judge Clay Jenkins, “When I called DCMS, they were like medical Minutemen! They were essentially an outreach of my office.” No other county medical society has the vision and innovative creativity to create a Project Access Dallas, serving thousands of uninsured patients in our community, and then transform that program into an 1115 Waiver program, My Medical Home. No other county medical society has the tenacity and determination to overcome political inertia and successfully drive a regional HIE to completion.

One does not get the true sense of the depth and breadth of the activities that constantly are churning at DCMS merely from reading the monthly journal or regular e-mail communications. If I have one criticism about Michael and his band of merry women (and now a few men), it is that they do not do a good job of tooting their own horn!

et Adieu

Michael Darrouzet, Connie Webster, Tracy Casto, Lauren Cowling, and Deanna Wooten

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President’s PageMichael, let’s work on this one! It is not until a physician gets involved on the board level does one get a real appreciation of the value of DCMS and the magnitude of the healthcare community’s dependence on and respect for DCMS. We truly are fortunate and blessed to work with such outstandingly inspired and passionate individuals. We are the envy of the state.

During my presidential installation speech in January, I noted that I don’t do humble well. After this year, I can safely report that this surely has changed. Working with the physicians, Michael, and the incredibly talented and dedicated individuals at DCMS truly has been a humbling experience — one for which I have been deeply honored. Thank you, one and all!

The two pieces of advice that I have for Cynthia Sherry, our incoming president, and Jeff Janis, our president elect, are that if Michael promises you that the president’s job is really not that hard or time consuming, and that after June it is all smooth sailing — don’t believe him for a minute. A greater example of false advertising does not exist. After all, mosquitoes and the number 1115 were never on my radar screen. And if Connie texts you on a Sunday morning with the message, “We have a problem and need to talk, please call!” think twice about doing so! It is not welcome news and your free time and life are about to change dramatically!

OK, just kidding. Here comes the real stuff.

“To Advocate for Physicians and Patients”This is my vision, through not only words but

also an image of the truly complete enlightened physician. Throughout the year, interspersed within my President’s Pages, I have touched upon this ideal. And it literally is etched in stone. As you walk into the entrance of my specialty society’s headquarters in Washington, DC, you are confronted with this new reality carved into the wall: “Quality care through science, education, and advocacy.” (See title photo.) The advocacy piece is the most important. As I stated in my installation speech, my goal for the year was to try to make physicians uncomfortable. That is, to get them out of their comfort zones as clinicians grounded in science and education. I stepped out of my comfort zone when I had to step into the political arena and advocate for Dallas County residents by presenting information about killing mosquitos to the Dallas County Commissioners Court, various city councils, scores of mayors, and in live radio and TV interviews. It was a little nerve racking because, as a private practice cardiologist, it had been at least 25 years since Jim Luby had taught me about arboviruses and Culex sapiens Quinquefasciatus. (Now try saying that one 10 times fast! Which reminds me … Michael, can I apply for CME for all that West Nile virus research I did?) It was through advocacy that the tide was turned and the correct decision for aerial spraying was made. The science

and education pieces were not getting it done. The lives that were spared the ravages of West Nile virus, through advocacy, are the result of the most satisfying role I could have performed as a physician.

“Above God and the Law”Several years ago, Frank Lutz administered a

poll of Americans to learn which professions they considered the most credible. At the top, by a significant margin, were nurses and physicians. We were far above judges, legislators and the clergy. Mr. Lutz proclaimed, rather dramatically, “In our society, you doctors are above God and the law!” We need to use that. We need to leverage this “coat of credibility,” as he called it. We have much more to offer than science and education. People want to know our opinions on a whole range of societal issues, especially healthcare reform. And they want us to fight for them. Society looks to us to lead, so let’s lead! The stakes could not be higher. The Affordable Care Act is merely a broad guideline. Nowhere in the document were P values, confidence intervals or guidelines referenced. The vast majority of decisions about how healthcare reform will manifest in our communities are yet to be determined from both the regulatory and legislative perspective. At both the state and federal levels, we need to be at the table and be involved.

There is an old vision of the physician as an advocate for his or her patient. This has to mean much more than just words. To quote the American College of Physicians’ Ethics Manual, “Physicians have an opportunity and duty to advocate for the needs of individual patients as well as for society.” This ideal is echoed in our DCMS mission statement, “to advocate for physicians and patients, to promote a healthy community.” This is our version of the well-know mantra “to protect and to serve.” This is the one area (and I mean only one!) where we physicians need to be much more like lawyers. Yes, yes, heresy, I know! Yet, it is admirable how attorneys will be a part of the political process, almost as if it becomes a part of their genome when they complete law school. In fact, the root derivation of the word “advocate” means lawyer, or legal counsel. The reality is that, as physicians, we will have just as much impact on the health care our patients receive by working in legislative chambers and boardrooms as we do practicing in exam rooms and operating suites. As clinicians we treat one patient at a time, but as physician advocates, we can help an entire state or country, all at once.

Through DCMS and our role as physician advocates for our patients, timely access to quality cost-effective health care is within our reach, and our shared vision of a healthy community is in sight.

Adieu, et a la prochaine!

Follow Dr. Snyder on Twitter @DCMSPres!

TMASeminar


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DCMS hosted a TMA Policies and Procedures Seminar in October, which was attended by more than 40 physician members and office staffers. The seminar detailed comprehensive and current policies and procedures that form the foundation of every medical practice.


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Join the ‘White Coat Invasion’First Tuesdays at the Capitolby Tracy Casto, director of public affairs and advocacy

Austin is preparing for the Return of the Legislators, and so are DCMS and TMA. Clear your calendar for First Tuesdays at the Capitol, starting on Feb. 5. Physicians, alliance members and medical students from around the state converge on Austin the first Tuesday of each month during the legislative session. Join a few hundred of your colleagues from across the state in the Descent on the Capitol to talk with legislators about issues that matter to you and your patients.

Your Patients Need YOU to Be a Lobbyist for a Day!Legislators say that “those white coats” in their offices and in the

gallery definitely kept dozens of bad bills at bay in 2011. The Legislature starts this session on Jan. 8 with an $11 billion budget deficit and serious challenges in funding Medicaid, providing access to care to the million new Medicaid recipients, and answering questions about end-of-life issues.

All you have to do is get to Austin. TMA will provide talking points and other printed materials, and brief you on the issues. DCMS will make appointments with your representatives and accompany you to your meetings.

The day’s activities begin at 7:15 a.m. at TMA headquarters, so you may want to get to Austin the night before. Meetings with legislators generally conclude about 3 p.m. Your day will be filled with discussions about Medicine’s issues. After the meetings, you’ll share what you learned with your colleagues and the TMA lobby team.

Medicine’s Voice Heard in Austin Physicians, medical students, and TMA Alliance members played a key role in passing TMA’s 2011

legislative agenda by personally lobbying lawmakers during First Tuesdays at the Capitol.

The white coats that filled the capitol hallways and the House and Senate galleries sent a powerful

message to legislators that TMA and physicians, students and alliance members would be watching as

they debated issues that are critical to Texans’ health.

F e b r u a r y 5 | M a r c h 5 | A p r i l 2 | M a y 7


ANESTHESIA CONSULTANTS OF DALLASwww.acdllp.comACD believes that in order to deliver quality medical care you must begin with well-trained physicians and require them to continually educate themselves and measure their quality outcomes and customer satisfaction. All of our physicians have earned their advanced medical degrees from highly respected academic programs and have gone on to distinguish themselves both professionally and academically. We have experts in every area of anesthesia, and all of our physicians are committed to staying on the cutting edge of the constantly expanding base of medical knowledge.

ATLAS ANESTHESIA ASSOCIATESwww.atlasanesthesia.comWe are the premier group of board-certified anesthesiologists dedicated to providing the best, most efficient anesthesia possible for your patients, while also providing the highest level of customer service to YOU, our surgeons. We accomplish our goal of excellence through a strategic emphasis on what we call a focus on the 3 S’s of ATLAS: Safety, Satisfaction, and Speed.

DALLAS ANESTHESIOLOGY ASSOCIATESwww.daadoctors.comDallas Anesthesiology Associates is a professional association of 21 board-certified physician anesthesiologists serving multiple hospitals and surgery centers throughout the greater Dallas area since 1962. Focusing on anesthesia for patients of all ages greater than 12 months, we provide the most up-to-date techniques for inpatient and outpatient general, orthopaedic, ENT, gynecologic, urologic, breast, and plastic surgeries. In addition to all forms of general anesthetic techniques, DAA promotes and practices the latest forms of regional and block techniques both for surgery and post-operative pain management.

DALLAS NEPHROLOGY ASSOCIATESwww.dneph.comDallas Nephrology Associates is one of the nation’s largest groups of practicing nephrologists. Since 1971, it has enjoyed the trust of its patients throughout the Dallas metropolitan area. DNA is a professional medical association consisting of physicians and other vital support staff, including nurse practitioners, physician assistants, nurses, laboratory and X-ray technologists, dietitians, social workers, technicians, and research staff. The practice has multiple locations in Dallas, Collin, and Tarrant counties.

DIGESTIVE HEALTH ASSOCIATES OF TEXAS, PAwww.dhat.comDigestive Health Associates of Texas, P.A., is the largest gastroenterology physician group in the country. The provision of high-quality, cost-effective patient care is the primary goal of DHAT physicians. By maintaining a staff of exceptional subspecialists, DHAT is uniquely qualified to deliver services supporting the full spectrum of an individual’s digestive health care. Our physicians share expertise, talent and technology to promote the patient’s positive outcome, comfort and quality of life. Excellent nursing staff and other healthcare professionals support our physicians.

EXCEL ANESTHESIAwww.excelanesthesia.comExcel Anesthesia is an all-physician anesthesia group dedicated to providing the highest quality perioperative care. Our group originated as a cardiac anesthesia practice in 1979. Excel Anesthesia attends to all facets of complex modern anesthesia practice. Excel Anesthesia is committed to continuing education, continuous quality improvement, and the incorporation of state-of-the-art monitoring and techniques in our practice. Excel Anesthesia strives to apply the principles of excellence to every aspect of every case.

METROPOLITAN ANESTHESIA CONSULTANTS, LLPwww.metroanesthesia.comMetropolitan Anesthesia Consultants is comprised of more than 45 physicians providing excellence in anesthesia care at many hospitals and surgery centers throughout the Dallas/Fort Worth Metroplex. Our commitment to our patients, surgeons and hospitals can be seen through the education, training and experience of each of our doctors. Under our physicians, patients can be assured that they are in the very best of hands for any type of surgery.

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PINNACLE ANESTHESIA CONSULTANTS, PAwww.pinnacleanesthesiamed.comPinnacle Anesthesia is dedicated to improving care of our patients through the prevention, evaluation, diagnosis, treatment, and rehabilitation of painful disorders. Pinnacle Anesthesia offers a variety of services and provides high-quality service to an extensive range of practice settings in over 100 locations throughout the Metroplex.

RADIOLOGY ASSOCIATES OF NORTH TEXASwww.radntx.comRadiology Associates of North Texas provides high-quality, value-oriented, diagnostic imaging and therapeutic services to our patients, referring physicians and payors in the North Texas medical community. Our focus through continuous improvement is to enhance the quality of life to all those we serve, both in the hospital and outpatient imaging environments. Our contributions enhance our reputation and ensure growth within the community.

RADIOLOGICAL CONSULTANTS ASSOCIATIONwww.rcaonline.netRadiological Consultants Association is a multispecialty radiology group based in DeSoto. We provide on-site hospital and outpatient imaging center coverage and teleradiology services. For more than 30 years, our team of board-certified, fellowship-trained radiologists has been committed to offering excellence in radiologic health care by providing the highest quality screening, diagnostic, and interventional radiology services to both patients and providers in our community.

TEXAS RADIOLOGY ASSOCIATESwww.texasradiology.comTexas Radiology Associates has been providing radiology services to the North Dallas community since 1972. We practice high-quality 24-hour hospital-based radiology. We are a large, dynamic group of more than 60 radiologists and represent every subspecialty of the exciting and fast-growing field of radiology. Most of our radiologists are fellowship-trained at leading institutions in subspecialties including interventional radiology, women’s imaging, neuroradiology, pediatric radiology, abdominal imaging, musculoskeletal imaging, cardiovascular imaging, MRI, nuclear medicine, and emergency radiology. As a result, we offer the full spectrum of diagnostic and interventional radiology services, including all modalities and both vascular and nonvascular procedures.

TEXAS SCOTTISH RITE HOSPITAL FOR CHILDRENwww.tsrhc.orgTexas Scottish Rite Hospital for Children is one of the nation’s leading pediatric centers for the treatment of orthopaedic conditions, certain related neurological disorders, and learning disorders, such as dyslexia. Admission is open to Texas children from birth to 18 years of age. Patients receive treatment regardless of the family’s ability to pay.

UROLOGY ASSOCIATES OF NORTH TEXASwww.uant.comWith 50 physicians and 20 locations throughout the Metroplex, we are one of the nation’s largest fully integrated urology practices. UANT is a unique combination of experienced and fellowship-trained physicians, utilizing state-of-the-art diagnostic and therapeutic facilities, with a commitment to excellence and a relentless pursuit of quality. This linking of medical professionals and the latest technology with a mission of delivering “world class” patient care has led to the development of our nationally recognized Centers of Excellence with fellowship-trained and experienced specialists in urology.

UROLOGY CLINICS OF NORTH TEXASwww.urologyclinics.comUrology Clinics of North Texas gives its patients excellent care and treatment of urological disorders, and delivers that care courteously, caringly and efficiently. We strive to provide highly positive medical outcomes, apply proven advanced technology and pharmaceuticals, and deliver care in locations convenient to patients throughout Dallas, Collin and Rockwall counties. We affiliate with hospitals and other physicians who share a reputation for excellence, and continuously expand and update our medical knowledge, skills and techniques.

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…To your Practice.The first place most patients turn for information about healthcare providers is Google. They’ll

usually start with your practice’s Web site, but second and third will be your Facebook page and Twitter feed. What message does a patient or potential patient get if you haven’t updated your sites in months? Facebook is the world’s second most popular Web site, and Twitter is in the top 10. Are you engaging these potential patients? Every successful plumber, personal chef, lawyer, and real estate agent has a social media presence. You should, too.

…To your Patients.A primary complaint of patients is how little time they are able to spend interacting with their

physician. Consider social media as your opportunity to engage with them where they are — in their day-to-day lives. You don’t have to answer a barrage of questions at all hours, but social media can give you a platform to connect your patients to news articles, healthy living programs and other information that will improve their quality of care, and the relationship between you and your patients.

…To Yourself.Social media makes the flow of information incredibly fast and easy. True, using social media

gives you a voice and connects you to patients, but it also can serve as an efficient way to keep current with the conversations in your medical specialty or community. David Miller, MD, a radiologist at Baylor University Medical Center, says:

“When used correctly, Twitter can be an incredible resource

for keeping up with important and up-to-the-minute information

related to the practice of medicine. Spending a few minutes

scrolling through my feed of sources I’ve selected gives me

more relevant information faster than spending hours combing

through Google or the major monthly medical publications to

find something that pertains to me and my practice.”

Social media matters…

[Social Media]


dcms Member Roundup

Linda Secrest with Drs. Les Secrest, Lisa Swanson and DCMS President Rick Snyder

Drs. Robert T. Gunby Jr. and Dee Whittlesey with DCMS CEO/EVP Michael Darrouzet

Joe Saad, MD, with his wife, Rana Daniel Depauw and Jessica Bradford, DCMS Circle of Friends members, with Drs. Richard Layman and Don Graneto

Lisa King, MD, with sons Ke’ei and King Hatley

DCMS Circle of Friends members Tonya Washington and Cindy Roach

Leyka Barbosa, MD, won an iPod Touch from event sponsor Blue Cross Blue Shield.

The 10th annual DCMS Member Roundup on Nov. 2 featured a Dallas School of Rock Band, lots of food, fun, and physicians’ families.


William Moore, MD, with daughters Juliet and Natalie

Quynh Ton-That, MD, with his son Luke; Jessica Paulin and Omar Saeed from MetLife Center for Special Needs Planning

Golder Wilson, MD, enjoys pool with his wife, Donna

Premier Sponsors Brandon Turman and Wes Windham of Envision Imaging

Theodore Simon, MD, with his wife, MarciaSophia Chung, daughter of Drs. Andrew and Wendy Chung, won an iPod Touch from event sponsor Blue Cross Blue Shield.

DCMS President Rick Snyder, MD, joins the Dallas School of Rock Band on stage

Lindsey Arviso, MD, with husband Chris, Campbell and Parker

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President’s Page“B as in Billions”

With this one I will be channeling my inner Carl Sagan, “Billions and billions.” And no, I am not referring to the number of words by which I have exceeded the limit of my collective President’s Pages to date. The billions I am focusing on are the more than $4 billion in supplemental federal and local money that Dallas hospitals are set to receive over the next four years to care for the county’s uninsured and Medicaid populations, while the physicians, the ones who actually provide the care for the patients, will receive next to nothing.

UPL and DSH, “Can I Buy a Vowel?” For the last several years, Dallas private

hospitals have been the beneficiaries of federal supplemental matching programs for the services that they provide for the uninsured and Medicaid populations. (Warning: this article will contain an excessive number of governmental mumbo-jumbo acronyms. However, these are terms with which we physicians all desperately need to become familiar, almost as familiar as SGR.) Two of the more important ones are the Disproportionate Share Hospital (DSH) and the Upper Payment Limit (UPL) programs. Medicaid DSH payments provide financial assistance to hospitals that serve a large number of low-income patients, such as people with Medicaid and the uninsured. Medicaid DSH payments are the largest source of federal funding for uncompensated hospital care. In 2009, roughly $11.3 billion was distributed nationwide, with Texas hospitals receiving approximately $960 million. UPL is a program that allows hospitals to be reimbursed for the difference between what Medicaid paid for the service and what the hospital charged, up to a certain cap, generally a Medicare rate.

Starting in 2007 in Dallas County, private hospitals and local governmental entities (Parkland Hospital District) formed affiliations that contributed funding needed to draw down the federal dollars available under the UPL program in a federal-to-state match ratio of approximately $1.50 to $1. This meant that for every $1 the county provided from qualified governmental sources, in this case the Parkland Hospital District, the federal government would match that with roughly $1.50 in an Intergovernmental Transfer. The intent of the UPL program was to expand inpatient and outpatient care for Medicaid and uninsured populations. Because the program reimbursed hospitals the difference between what Medicaid paid and what the hospital charged,

this created a misaligned incentive for hospitals to increase their charges. Because hospitals aren’t required to report how they use the UPL funding, taxpayers (and physicians) couldn’t see how the dollars were being used. In terms of UPL funding, the enhanced federal matching dollars meant more than $250 million annually to Dallas County hospitals to bridge this hospital Medicaid cost-to-charge gap.

When taken together, the DSH and UPL programs have meant north of a billion supplemental dollars to Dallas County hospitals on a yearly basis for the care they provided for the uninsured and Medicaid patients. Wait a minute, did I say for the care they alone provided? That is the little known fact that no one wants to talk about— how Dallas public and private hospitals receive eye-popping sums of supplemental governmental funds for care provided, mostly through physicians, to uncompensated and Medicaid populations, while the physicians themselves realize next to nothing.

Now, all of this is about to change.

The Waiver On July 13, 2011, the Texas Health and Human Services Commission submitted a proposal, “Texas Healthcare Transformation and Quality Improvement Program,” aka “The Medicaid 1115 Waiver” or “The Waiver.” If you suffer from an extreme form of insomnia or are an obsessive-compulsive health economics geek, please see the DCMS Web site for the original 110-page document. The proposal, which was approved on Dec. 11, 2011, is a demonstration waiver under Section 1115 of the Social Security Act. Simply put, the 1115 Waiver allows the state to expand Medicaid managed care as a percentage of the total Medicaid program. It does not change who is eligible for Medicaid; it just shifts a greater percentage of traditional Medicaid patients into a managed care plan. Think Star and Star-Plus. By shifting more patients from traditional Medicaid into a risk-based, managed care model, the state intends to control costs while improving coordination of services and to preserve federal funding for hospitals. (Wait a minute … controlling costs by shifting more patients into a capitated, risk-based managed care model, which we all know is accomplished principally by physicians in the outpatient setting at a loss, just to preserve billions in federal and local supplemental funding sources for hospitals? What am I missing in this picture? More on this later.)

When a Waiver is Not an Expansion The Medicaid 1115 Waiver should not be confused with the Medicaid Expansion as called for in the Affordable Care Act (ACA). The Medicaid

1115 Waiver is NOT part of the ACA. The Waiver does not expand the Texas Medicaid population or who is eligible. The Waiver shifts more Texans from current traditional Medicaid into managed care Medicaid. The Medicaid expansion promoted by the ACA expands Medicaid to more uninsured populations without making it more efficient, and definitely increases cost. For example, if the ACA Medicaid expansion were fully implemented in Texas, it would add more than 2 million people to the Medicaid program and cost the state more than $27 billion over 10 years. On the other hand, the Medicaid 1115 Waiver puts a greater focus on reducing costs by paying for improved quality and efficiency.

A waiver is needed to accomplish this because federal rules generally cause that states that expand managed care for Medicaid see a reduction in funding to hospitals under the UPL program. The idea is that if the state realizes a reduced cost benefit by shifting a greater proportion of their traditional Medicaid patients into a managed care Medicaid program, then the federal government should also receive a cost benefit and should not have to fund some of these hospital supplemental Medicaid matching programs to the same level. In the Waiver, Texas requested federal approval to redirect the UPL funding at the same par level it would have received over the ensuing five years, more than a billion dollars (and change!), while expanding the Texas Medicaid managed care program. The Waiver does not bring more money to the state; it merely allows the state to preserve the federal funding it would have received benefitting the hospitals if managed care were not expanded. The new funding program under the 1115 Waiver consolidates the programs by combining the hospital UPL funds, physician UPL funds and DSH funds with the savings generated by expanding managed care, and creates new funding pools that will be used to help improve healthcare services and reimburse hospitals for uncompensated care. These new funding pools go by the names Uncompensated Care Pool (UC) and Design System Reform Innovation Project Pool (DSRIP). Remember these acronyms like you would your kids’ initials because the numbers associated with them are Carl Sagan-like. The Waiver also seeks to increase local control over how key Medicaid funds are used and intends to make the payment process much more efficient, transparent and accountable. Consequently, taxpayers (and physicians) should be able to know exactly how their money is being used. The end result is a Medicaid system that should reward performance and make better use of tax dollars. The only real question is, whose performance is being rewarded?

In the Waiver document introduction, the “overarching goals” of the proposal are revealing: “Expand risk-based managed care statewide; Support the development and maintenance of

a coordinated care delivery system through the creation of Regional Healthcare Partnerships; Improve outcomes while containing cost growth; Protect and leverage financing to improve and prepare the healthcare infrastructure to serve a newly insured population; Transition to quality-based payment systems across managed care and hospitals; Provide a mechanism for investments in delivery system reform including improved coordination in the current indigent care system now providing services to individuals likely to gain coverage in 2014.”

The document states that the proposed demonstration will transform the delivery of care and payment systems into one that is more “transparent and accountable.” This is unlike the previous funding programs (UPL and DSH) that the new system will replace. These overarching goals reveal a program that is not only patient-centered, but one that must be, by its very nature, physician-centered as well.

The proposal introduction provided specific elements that all relate to the overarching goals:“Flexibility to direct Waiver savings into a pool to cover uncompensated care costs by hospitals and other providers (that is code for you and me); Flexibility to reinvest waiver savings for delivery system reforms that expand provider capacity, improve care efficiencies, and align provider incentives in a manner that promotes quality and helps prepare providers for healthcare expansion in 2014.”

Clearly, fundamental to the transformative goals and elements of the Waiver demonstration project is the primacy of the physician in the delivery of care in the inpatient and especially the outpatient settings. The take-away point is that the success (or failure) of the 1115 Waiver’s Overarching Goals and Elements hinges on the central role of the physician in this whole process. The problem, however, is that despite what the document explicitly proposes, reimbursement to physicians largely has been ignored in the discussions of the various committees to date.

The Waiver details how the cost savings will come from managed care expansion that will be redirected into the UC and DSRIP Pools, primarily benefitting hospitals but also should benefit physicians. Under Texas Medicaid managed care, the state pays a health plan a set fee each month to provide health care for a Medicaid client. The client selects a primary care provider from the plan’s network, and that doctor coordinates the client’s care. The Star program is Texas’ primary Medicaid capitated Managed Care Organization (MCO), serving 1.3 million enrollees out of a total Medicaid population of around 3 million. Star-Plus is an integrated delivery system of acute care services and community-based long-term services. As the proposal states, “the full-risk capitated managed care approach also offers the maximum cost control to the state.... Under the full-risk model, MCOs have incentives to


coordinate care and services that reduce cost of inpatient care, over-utilization of prescription drugs, and other expensive categories of health services.” (Hmmm, this sounds a lot like a rationing mechanism. See my November President’s Page.)

On Page 4 of the document, the Waiver proposal states that the Star MCOs “must improve access to physicians per contract requirements, which include access to routine, urgent and emergency care.” This requirement was confirmed in a Nov. 7, 2012, public hearing in Dallas concerning the Waiver. The Community Needs Assessment Task Force listed as the top priority for Dallas County “primary and specialty capacity,” highlighting that the “demand exceeds available medical physicians in these areas, thus limiting healthcare access.” The proposal also specifically reinforces the need for “reduced admission rates for such chronic conditions such as COPD, CHF, diabetes,” and preventive services such as “well-visits, HbA1c testing, LDL-screening.” The Needs Assessment Task Force agreed, listing “Chronic Disease, Adult and Pediatric” as the third priority. This screams of outpatient physician-directed care. The Waiver goes to great length to emphasize the value of the MCO members having a long-term, well-established personal outpatient physician to “coordinate care,” which reduces costs and performs these other preventive services.

The main problem here for Dallas County is that only 19 percent of PCPs accept traditional Medicaid, and that number has been in a free fall for the last several years. Medicaid managed care plans generally pay even less, and, as a consequence, have even less physician participation. This has created insurance coverage with merely the illusion of access. As I have stated before, coverage is not the same thing as access, and access to a waiting list is not access to health care. The Waiver explicitly states that real access to physicians, not just coverage, must be improved. I agree that access is being improved as the details of the Waiver are beginning to materialize, but it is not access to physicians. How can one justify a program that hinges on the central role of physicians to coordinate care, reducing cost to the state (while the physicians themselves lose money with each patient they see), but that principally benefits hospitals by preserving their access to supplemental governmental funding sources exceeding a billion dollars annually? The primary access point by which low-income patients (uninsured and Medicaid) enter the hospital system is through the emergency department. Remember that hospitals are exposed to the risk of caring for the uninsured and Medicaid patients in the ED by federal mandate via the EMTALA law. (Oh no! There is that word again— mandate! I thought the Supreme Court redefined it as a tax!) EMTALA requires hospitals to provide a call list. It is a myth that EMTALA forces/mandates physicians to serve on ED call lists to serve the unassigned. We are “mandated”

to serve on ED call lists by our own hospital bylaws, not by the federal government.

As the Old Saying Goes, “Follow the Money!”Quietly, a titanic struggle is raging in Dallas

County boardrooms over the destination of these billions of dollars (and change!) in federal matching funds that hospitals have been receiving annually. The Waiver does not alter the amount of public funding that is available to hospitals; in fact, that was the main point — the Waiver preserves the funding. The 1115 Waiver waives the federal requirement to decrease the amount of money paid to hospitals collectively if Medicaid managed care is expanded. It does, however, change how that money is distributed. Under the plan, public and private hospitals that treat large numbers of uninsured and Medicaid patients, AND provide the best services, will get the most funding. Texas’ uncompensated care totaled $15.1 billion in 2009, and while the hospitals bore the majority of these costs, the physicians took on a substantial part of that burden, as well. It is a testimony to the vast amounts of dollars at stake that the CEOs themselves of the hospital systems (Baylor, THR, HCA, Methodist, and Parkland) are serving on the boards that are addressing this issue. Your DCMS staff and the TMA are at the table of these discussions, as required by the Waiver. It is necessary and appropriate for medical societies to be involved because the Waiver clearly calls for the use of these new funding pools to include physicians to reimburse them for the roles they play in this program.

The UC and DSRIP Pools are intended for the “development and maintenance of a coordinated care delivery system through Regional Healthcare Partnerships (RHPs, Dallas and Kaufman counties are in Region 9) and to provide a mechanism for investments in delivery system reform. The funding pool will have two distinct components for which federal participation would be requested: payments to hospitals and other eligible providers to cover uncompensated care costs (UC Pool, approximately $850 million the first year), and a delivery system reform incentive payment program for hospitals (DSRIP Pool, approximately $250 million).” Note the language for “other providers.” See the DCMS Web site for proposed breakdown by hospital.

Now UC It, Now U Don’tThe document further states that included

in the funding pools will be “supplemental payments allocated through the physician UPL program and cost efficiencies achieved from moving populations and services to risk-based managed care.” In other words, not only do these funding pools include the traditional hospital funding sources that hospitals enjoyed for caring for the uninsured and Medicaid populations (on the backs of physicians) via the UPL and DSH


mechanism, they also include the savings that we physicians will generate through managed care cost reductions and a redirection of physician UPL into the Medicaid 1115 Waiver funding streams.

Yes, that’s right. I said “physician UPL program.” How many of you have heard of a supplemental reimbursement program for physicians? It has been in existence for several years but hasn’t been very well advertised. If you’re unfamiliar with it, don’t worry; it’s being redirected into the Medicaid 1115 Waiver process. But, as noted on Page 12 in the section titled “Continuation of Enhanced Payments to Physicians” (Continuation? I didn’t know we were supposed to be getting enhanced payments to begin with!), “Texas also proposes to continue to provide enhanced payments from the UC Pool to physicians serving Medicaid. UPL physician payments are included in the ‘without waiver’ calculations and in the UC Pool under ‘with waiver.’”

Throughout the document, enhanced physician payments through the UC Pool are mentioned repeatedly, reinforcing their essentialness to the success of the Waiver. This begs the question, where are the enhanced physician payments?

The Forgotten “Other Healthcare Providers”At the Nov. 7, 2012, public hearing concerning

the Waiver, the publically furnished documents (see DCMS Web site) echo the original intent of the proposal to include physician participation in the UC funding streams. “The Uncompensated Care Pool payments are designed to help offset the costs of uncompensated care by the hospital or ‘other healthcare providers’.” However, this element of the original proposal has been conveniently forgotten.

Furthermore, through the DSRIP Pool, physicians will continue to play the central role. Novel, transformative and innovative care delivery projects are the key descriptors to this funding pool. Texas proposed to design the DSRIP as “the vehicle to support coordinated systemic care and quality improvements through Regional Healthcare Partnerships…. The incentive payment program seeks to transform hospital care delivery systems by delivering proactive and planned prevention and primary care services for all patients; increasing patient access by expanding the primary care workforce; and offering timely, proactive, coordinated medical home care from a multidisciplinary team that is highly adept at managing chronic disease.” The document states, “Texas would make a future adjustment to the ‘without waiver’ budget cap to reflect payment increases up to Medicare levels in 2013 and 2014 for primary care services.” Clearly, this suggests that the minimum enhanced physician care payments should be to Medicare levels.

At the public hearing in November, this notion was echoed in the DSRIP Pool payment description as “incentive payments to hospitals and other healthcare providers that develop programs

and strategies to enhance access to health care, increase the quality of care, improve the cost-effectiveness of care, and benefit the health of the patients and families served.” Again, the “other healthcare providers” is code for the group that includes the physicians. These proposals cannot be accomplished without including doctors in the reimbursement mechanism, as the original Waiver proposal intended. Unfortunately, with only 19 percent of Dallas County PCPs participating in Medicaid due to inadequate reimbursement, this will not be possible.

“Quality, efficiency, cost-reduction, coordination of care, enhanced community and home-based services, risk-based managed care, enhanced primary care, and preventative services” are all goals of the Texas Medicaid 1115 Waiver mechanism that are repeated throughout the document. They also are the keys to the success of the demonstration that lie predominantly with the physician. Health care is provided through physicians. I have never seen a hospital system or its CEO listed on a call roster, or serving as an attending or consultant. Guidelines and Appropriate Use Criteria are written by, and for, clinicians. Thus, it is only through the physicians that the aims and goals of the Waiver, “Texas Healthcare Transformation and Quality Improvement,” can truly become manifest. And that is precisely why the physicians must figure much more prominently in the Waiver planning process and reimbursement mechanism. It is only pragmatic to do so. If only 19 percent of PCPs participate in a program designed to meet the needs of our current Medicaid population and the needs of the 30 percent of the county who are uninsured but who may become insured in 2014, we clearly need more. The only way to do that is to enhance payments to physicians as explicitly called for in the Texas Medicaid 1115 Waiver.

This is not about physicians trying to do a money grab and lay claim to a revenue stream purely for self-interest. If independent physician practices cannot maintain economic viability as a consequence of their participation in this program, they will be forced to withdraw from the Medicaid insurance program (as many have already done) or go bankrupt. This does not serve the interests of any of the parties involved: hospitals, physicians, patients, or the local community. This just perpetuates the illusion of access. Your DCMS staff has been at the table with the hospital systems for the last 9 months as a key stakeholder; however, to a certain extent we are out-gunned and out-manned. We have been participating in good faith and trust. Unfortunately, decisions made by the hospitals late in the process have undermined this trust. The original stated goals of the Waiver funds have been clouded, diluted and redirected. The “enhanced physician payments” that were discussed in the UC tool of the original Waiver proposal have been lost in recent funding


proposals. We need the participation and support of all

physicians to make this program work, not only from a clinical standpoint, but also from the original design perspective. From a practical standpoint, how UC and DSRIP care manifest at the hospital and outpatient levels mostly is determined locally at each specific hospital location. Many of these programs and innovative projects, such as indigent care clinics and coordination of chronic disease management, are unique to specific hospitals, systems and their aligned physician medical staffs. One of our main concerns is that physicians will be unknowingly “drafted” by their affiliated hospitals or 501A to provide both inpatient and outpatient care for these patients on a charity basis, thus allowing the hospitals to draw down supplemental federal dollars at an astonishing rate.

Consequently, local physician hospital and system leaders will have to provide direction on how those “enhanced physician payments” should and must specifically manifest to their particular medical staffs and physician system affiliations. One possible mechanism is to make enhanced payments to those who serve on call schedules. Another is to reimburse physicians to at least a Medicare rate for outpatient services through a DSRIP program such as DCMS’ My Medical Home (the new Project Access Dallas 2.0). I am sure there are other “innovative and transformative” enhanced physician payment mechanisms we can propose. DCMS is ready to assist Dallas physicians in this process. It is, however, incumbent upon the DCMS membership to invest themselves in the process, learn the nuances of the current and emerging funding mechanisms and the innovative delivery models, partner with DCMS, and become leaders in their local physician communities. The big winners would not only be the hospitals and physicians, but especially the patients and Dallas County as a whole.

The Big Question?My primary question is worth repeating:

how can you ask the physicians to continue to subsidize hospital systems by seeing low-income patients at a loss, just to preserve the hospitals’ draw-down of supplemental governmental payments estimated in the eye-popping range of $4 billion to $5 billion over the next four years?

Only Carl Sagan could know! “Billions and billions!”

See www.dallas-cms.org/waiver.cfm for more info.

Follow Dr. Snyder on Twitter @RickSnyderMD!


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Q: The US Census reports that Texas is ranked first among states with the highest percentage of uninsured Texans, 5.8 million persons. Is that something that we should be immediately concerned about?

A: The short answer is “yes,” and you do have to ask yourself why it’s like that. We are the state with the largest continuous border with our southern neighbor, and I don’t think there’s any question that affects things.

It’s very famous that Massachusetts took a bold step in healthcare reform, and one of their folks came down to Congress to talk about that when it was happening back in 2006.

And I asked, “What is your approach to people who might be in your state without a Social Security number?” And they said, “Why would anyone be in your state without a Social Security number?” I said, “I can think of a reason, or two, or five million…”

You cannot construct a system in which you just don’t worry about that portion of the population. When we talk about healthcare reform on a national basis, the president wants to take what they did in Massachusetts and apply it to everyone. But, it’s not going to work because they had ignored what is our biggest problem here in Texas, which is our uninsured population.

Now, in Texas we do have a pretty robust safety net. I know — I worked at Parkland Hospital for 4 years in private practice. Twenty percent to 25 percent of the deliveries I did each month were from people I had never seen before and would never see again. But, we always took care of people and never turned anyone away…. Of course, in our larger institutions, which do receive federal monies from the Disproportionate Share (DSH) and the Upper Payment Limit (UPL) funds, they actually have a revenue stream that they can depend upon to take care of that proportion of the population.

One of the ways that the ACA is paid for is recapturing that money from hospitals that receive DSH funds. That is to say, that everyone is going to have insurance, so why do the hospitals need that extra money? No one will be uninsured, so the hospitals won’t need extra money, so the federal government takes it back. Well, except that the president of the United States said that no one who is in the country without a Social Security number is going to participate in the program.

Q: Are the problems you have with the ACA so great that you would rather see it go away than see 3 million additional Texans insured by 2014?

A: It’s not that you don’t want anything in the ACA. In fact, there were a number of things that were already being worked on when the ACA came along.

The biggest problem that all of us (Republicans) had is not addressed in the ACA: costs. In fact, it’s made it worse. That’s Governor Romney’s famous line — it promised a $2,500 reduction in premiums, but it actually went $2,500 the other way. It’s a $5,000 swing, which is going to affect families in a big way. Rather than tackle the No. 1 problem that was facing everyone, which is costs, the president decided to go for coverage first. But even there, after this is all implemented in 2014, you are still going to have 27 million people uninsured in this country, and Texas is likely to have the lion’s share of that.

Q: In Texas, we have made a decision as a state to not take advantage of the opportunity to expand Medicaid. There are a lot of people who say that if you do not expand Medicaid, you are asking for trouble, given the large population of uninsured in this state. What is your sense of the Medicaid program and what a state like Texas should be obligated to do?

I’ll be the first one to say I’m not always on the same page with the governor, but in this case, he was right. It’s a bait-and-switch. You get free money for 2 years, and then some almost free money for a year or 2 after that.

Look at the problems we’re having in Medicaid today; the projected unfunded liability in Medicaid is $70 billion over the next 75 years. It is a huge amount of money. Why in the world would we do anything else to make that worse? You can say it is 100 percent free money to the state from the federal government, so why wouldn’t the state take that money? Because at some point in the very near future, it runs out. And when it runs out, you have expanded your roles phenomenally…. The federal government has been such an unreliable fiscal partner (ask any doctor) that I do not quarrel at all with Governor Perry being circumspect about this offer because it looks too good to be true. It is.

A Conversation withMichael Burgess , MD

Republished with permission.

Original story by Evan Smith, The Texas Tribune, www.texastribune.org.

Original article can be found at www.texastribune.org/texas-news-media/triblive/triblive-a-conversation-with-michael-burgess/.

In October, Texas Tribune editor Evan Smith sat down with Texas Congressman Michael Burgess, MD (R-26), about the future of Medicaid and Medicare, Texans without insurance, and the Affordable Care Act. Below is a portion of the interview. The entire interview can be seen at www.texastribune.org or www.youtube.com/thetexastribune.

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The redesigned site offers quick and simple access to updated information related to NTAHP and the NTAHP HIE in a user-friendly format. In addition to general information, it contains sections that are tailored to the individual groups that benefit from the NTAHP HIE: patients, physicians, hospitals, payors, and employers. “We are making excellent progress in our efforts to connect the North Texas region via the Health Information Exchange,” says Joe Lastinger, CEO. “Our Web site will be a valuable tool to help us connect to patients, physicians, hospitals, and payors in order put them on the path to connection.” The new Web site is vital to educating the community about NTAHP’s mission, and the importance of information accessibility on the Internet is no secret. HIE information that can be accessed easily by the North Texas community will be a major factor in its ongoing success.

The new Web site is an excellent platform to provide information about the upcoming capabilities of the robust, web-based HIE, such as the ability for query-based exchanges and a longitudinal record that travels with the patient, but also Health IT solutions such as NTAHP DirectConnect. Communication of

health information among providers and patients still relies mainly on mail or fax, which can be slow, inconvenient and expensive. Health information and history can be easily lost or difficult to find in paper charts. NTAHP DirectConnect is a secure, encrypted means of communication that is similar to e-mail and which allows physicians, nurse practitioners, physician assistants, and other healthcare providers to share information easily. Healthcare providers can utilize NTAHP DirectConnect’s point-to-point exchange to share information such as patient care coordination, referrals and diagnostics. Along with more efficient communication, physicians who subscribe to NTAHP DirectConnect are closer to achieving Meaningful Use, specifically, Stage 2 objectives of exchanging referrals electronically.

NTAHP invites physicians to explore our Web site as they continue to make strides toward the goal of improving and rewarding cost-effective, transparent health care for North Texas.

For more information about NTAHP DirectConnect or the NTAHP HIE, please visit our Web site, www.ntahp.org, or call 817.274.6300.

The North Texas Accountable Healthcare Partnership continues to gain momentum, as

evidenced by the progress of the Health Information Exchange implementation; the offering

of additional health IT solutions, such as NTAHP DirectConnect; and an updated Web site,

www.ntahp.org.

NTAHP: Connecting the Healthcare Communityby Kela McDermott, NTAHP Marketing Manager

40Y E A R S

SINCE 1971

Dallas Nephrology Associates (DNA) is a national leader inproviding complete care for patients with kidney disease,transplants, hypertension and complicated metabolic disorders.

DNA treats patients with the respect they deserve, helping them and their families face treatment with dignity by providing useful information and compassionate care.

1420 Viceroy Dr.Dallas, TX 75235

13154 Coit Rd., #100Dallas, TX 75240

1150 N. Bishop Avenue, # 100Dallas, TX 75208

3601 Swiss Ave.Dallas, TX 75204

2651 Bolton Boone Dr.DeSoto, TX 75115

1250 Eighth Ave., #500Fort Worth, TX 76104

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4927 Lake Ridge Parkway, Suite 100Grand Prairie, TX 75052

2020 State Highway 114, #190Grapevine, TX 76051

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701 Tuscan DriveIrving, TX 75039

4510 Medical Center Dr., # 309McKinney, TX 75069

5308 N. Galloway Ave., #200Mesquite, TX 75150

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1305 West Jefferson #160Waxahachie, TX 75165

Dallas Transplant Institute 3604 Live Oak St., #100Dallas, TX 75204

Vascular Centers: 3604 Live Oak St., #100Dallas, TX 75204

4401 Tradition TrailPlano, TX 75093

214-358-2300877-KIDNEY (877-654-3639)

“Serving the Dallas Metroplex since 1971”www.dneph.com

Dallas Transplant InstitutePre and Post Transplant Care | 3604 Live Oak Street, #100, Dallas 75204

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Parkland Foundation Celebrates Generosity of Medical Community

Parkland Foundation hosted an event Sept. 26 to

celebrate the generosity of the medical community to the

“I Stand for Parkland” capital campaign. The evening

included remarks by the Physician Council Cochairs Drs.

Kathryn Waldrep and Roberto de la Cruz, hard-hat tours

of new Parkland hospital facilities, and the opportunity to

view the newly opened model rooms.

Drs. Waldrep and de la Cruz announced that the

Foundation had raised $108 million of the $150 million

goal for philanthropic support for the new Parkland

hospital. The medical community has been most generous,

raising more than $1.4 million of that total. The first

$1 million in physician giving was matched by the Dr. Bob

and Jean Smith Foundation for a total of $2.4 million to

date.

The campaign will continue through 2014. To learn more,

visit www.IStandforParkland.org or call 214.266.2000.

DCMS CEO/EVP Michael Darrouzet speaks with Kathryn Waldrep, MD

Foundation supporters on the bus to the hard-hat tour

Drs. Roberto de la Cruz and Kathryn Waldrep

Donald Seldin, MD, with Ellen Taylor Seldin

Shirley Coln; DCMS staffers Connie Webster and Michael Darrouzet; Dale Coln, MD,

Richard W. Snyder II, MD; and Cheryl Prelow

At least 32 million U.S. households own

insurance policies that aren’t right for them.1

Make sure you have the right insurance to help you protect the life you’ve worked so hard to build.

1. Insurance Information Institute. “Changes in Your Life Can Mean Changes in Your Insurance, Says the I.I.I.,” Press Release, January 22, 2007.

NO.

7th i ng s p hys ician s n e e d to k now about i n s u rance

Talk to a TMAIT Advisor about insurance for you, your family, and your medical practice. TMAIT is exclusively endorsed by the Texas Medical

Association, and we are committed to helping you find the right coverage from an array of plans, including medical, dental, vision, life,

short-term disability, long-term disability, long-term care, and office-overhead expense.

Call 1.800.880.8181 [email protected]

Request a quote at www.tmait.org

O F N O R T H T E X A S

817-321-0300www.radntx.com

The 110 physicians of Radiology Associates of North Texas areproud to celebrate our 75 year commitment to excellence in radiology!

Our 14 outpatient imaging centers, 24 hospital locations and unparalleled subspecialtydepth provide you and your patients with a level of care that is unmatched in North Texas.

Thank you for partnering with us in the care of your patients.

December 2012 Dallas Medical Journal

Documents

Transcript of December 2012 Dallas Medical Journal