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25 May 2018

Dr. Karen Nichols — Physician, Administrator and Advocate

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May 25, 2018 Category: Local Posted by:

ABOVE PHOTO:  Dr. Karen Nichols

At AmeriHealth Caritas — a managed care agency that serves more than 5.7 million members nationwide — 77 percent of their  associates are women, 43 percent of who are part of its executive team. One of them is Dr. Karen Nichols, M.D.

By Amy V. Simmons

Dr. Karen Nichols is the medical director for the Pennsylvania Medicare plans at AmeriHealth Caritas, a managed care organization that provides health care coverage for people eligible for both Medicare and Medicaid benefits, according to her official company bio.

She oversees all the clinical interventions for the dual eligible special needs plans (D_SNPs) in Pennsylvania. She also provides oversight for the Medicare-Medicaid plan (MMP) demonstrations in South Carolina and Michigan as needed.

Nichols believes that the influence of women on decision and policy making in the organization is a good thing.

“In general, I think women think differently about things,”  she said. “What is important to women is sometimes different than what’s important to men. It’s good to have both perspectives.”

Growing up, strong female role models in her family were instrumental in Nichols’ life; this was especially important when she was pursuing a career in medicine.

“There were very few women of color in the roles where I was headed for me to look to for inspiration,” Nichols said. “The celebrities just didn’t do it for me. I always looked to the women in my family who were strong, intelligent, and independent. They pushed me to go further than any of them had.”

After earning her Doctor of Medicine degree from Temple University School of Medicine, Nichols became interested in geriatric medicine while completing her residency. 

In spite of her impressive career, the Girl’s High graduate (Class of 1975) considers motherhood as being her greatest accomplishment in life. She has two adult children — a son who is approaching his 30th birthday and 24-year-old daughter. She is extremely proud of them.

“They’ve grown into really terrific adults,” Nichols said. “My son is an electrical engineer, and my daughter works backstage at a theater, and ultimately wants to direct, but right now she’s assistant stage manager.”

In addition to her work with AmeriHealth Caritas, Nichols hosts a health-related radio program twice monthly on WURD 900 AM (96.1 FM). The program is broadcast from various senior centers and housing facilities located in Philadelphia.  Among additional positions she holds, Nichols also serves on the board of the LGBTQ Elder Initiative.

In her role at AmeriHealth Caritas, Nichols works to ensure that members are getting everything servicewide that they need, helping them to enjoy the best quality of life possible.

There are a number of medical directors in the company overseeing various categories of care and service. Nichols said that her role as medical director for the Pennsylvania Medicare Plans is largely administrative.

“I am instrumental in making policies in various parts of the division within the company,” she said. “I oversee our medical management department, which involves care managers who interface with our members. Care managers are advocates for the member, as well as their contact person if they [the members] have questions about their benefits, if they want to change their doctor, or have questions about their health.”

Nichols also oversees the utilization department, which responds when providers call and request certain services for members, makes sure that these services are being utilized appropriately, and that everything complies with CMS [the Centers for Medicare and Medicaid Services] regulations.

Prescription medication plays a huge role in the life of seniors. Proper prescription management, patient education and oversight is crucial.

“I’m also involved pretty much anywhere I interface with our pharmacists to make sure that the medication arm is appropriate as well, and I do some community outreach,” Nichols said.

No two work days are alike for Nichols, but all share a common goal.

“On any given day, I could be doing a number of different things, but they are all based upon getting clinical care out to our members,” she said.

Year-round healthcare initiatives are a major part of the services that AmeriHealth Caritas provides.

“In terms of initiatives for our population[seniors utilizing Medicare services] we try to do a lot of general healthcare screenings,” she continued. “We also have a big push for women to get their mammograms. We have an arrangement with Fox Chase Cancer Center where we’ll have them bring their mobile van to various activities.”

When taking into consideration the nature of medical research — where patient care guidelines for all ages and genders are constantly in flux — Nichols is hopeful.

“The longer you research something, the more information you gain…that’s actually a good thing — that’s not a bad thing.” she said. “We’re constantly — as a profession — trying to refine the information that we give to people. We try to keep up and put out the most current information with the disclaimer that we’re not in the business of prescribing care for anyone, and that any advice that we give, you should really talk it over with whoever your doctor is.”

Nichols encourages everyone — including other women — wishing to go into the healthcare field to consider all of the disciplines that it encompasses, such as nursing, physical therapy, pharmaceutical or cancer research, fitness, nutrition, among many other specialties.

“If anyone is interested in ‘sciencey’ kinds of things, but also has a certain amount of compassion for other people, I would say look into  [all] health related fields,” she said. “Not everybody has to be a doctor. It’s a very long process to get there. It can be arduous and can be extremely expensive. There are a lot of other aspects of healthcare where you can make a difference.”

Nichols envisions a new, more individualized model for patient care going forward.

“As time moves on, I think that we need to get away from the typical medical model that’s been around, where everybody goes to the doctor, and you sit there for an hour and a half, and the doctor writes you a script, then says ‘see you later’, and you go home,” she said.

“We have to change our perspective and meet people in the communities where they are and help people with their own goals, which are sometimes very different from what I as a physician might have as a goal for them.”

For more information about AmeriHealth Caritas and the programs and services they offer in the region, visit:

About Keystone First VIP Choice and AmeriHealth Caritas VIP Care

Keystone First VIP Choice — a (HMO-SNP) — launched on January 1, 2013. Backed by more than 35 years of expertise in caring for those most in need, Keystone First VIP Choice is helping the most vulnerable people in the Philadelphia area access quality health care. It helps with things like managing diabetes, taking the right medicine, and getting to the doctor. Keystone First VIP Choice is available in five Southeastern Pennsylvania counties: Philadelphia, Montgomery, Delaware, Bucks, and Chester.

On October 1, 2017, the company  began marketing AmeriHealth Caritas VIP Care (HMO-SNP) under its new name. It is another Medicare Advantage special needs plan for individuals enrolled in Medicare and Medicaid programs (dual eligibles) in selected counties of Pennsylvania including Lancaster, Lehigh, and Northampton. On January 1, 2018, they added the following counties:  Berks, Lebanon, Dauphin, Perry, Wyoming, York, Lawrence, Beaver, Washington, Greene, Butler, Allegheny, Armstrong, Westmoreland, Fayette, Indiana, Cambria, Somerset, Blair, and Bedford.

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