Colorado Medical Society and Colorado HMO Association White Paper on PHYSICIAN AFFILIATION/DISAFFILIATION

I. INTRODUCTION

A number of factors have resulted in expansion or contraction of panels of physicians which contract with HMOs. Such factors include, but are not limited to the following: growth in HMO enrollment; intense competition among HMOs and insurance carriers; PPO development; development of Physician-Hospital organizations; and Employer Report Cards (Health Plan Employer Data Information Set [HEDIS]). The affiliation/disaffiliation process has significant implications for the physician, HMO member and the HMO.

II. PURPOSE AND SCOPE

The purpose of this White Paper is to address issues of mutual concern arising in the affiliation/disaffiliation process among physicians and HMOs.

The Colorado Medical Society (CMS) and the Colorado HMO Association (CHMOA) recognize that the relationship between a physician and an HMO is voluntary and contractual in nature. It is not the intent of this White Paper to alter current contracting practices between HMOs and physicians. This White Paper should not be construed as endorsing physician disaffiliation solely "for cause" or an adversary hearing process for disaffiliation.

CMS and CHMOA believe that issues arising among physicians and HMOs could be ameliorated by enhanced communication between physicians and HMOs. They wish to develop an alternative to the expensive and time consuming adversary hearing process, while emphasizing mechanisms for dispute prevention.

Affiliation/disaffiliation issues involving quality of care or professional competence of physicians which lead to termination "for cause" are outside the scope of this White Paper. Such matters have implications under both state and federal law.

This White Paper contains the views and commitments of CMS and the CHMOA. However, each organization is comprised of individuals whose adherence to the views stated herein may differ. Some HMOs contract with groups of physicians (e.g., IPAs) which have primary responsibility for affiliation/disaffiliation actions. The recommendations of this White Paper are applicable to such groups of physicians as appropriate. The actions contemplated by this White Paper are recommendations which may or may not be adopted by an individual physician, groups of physicians or each HMO.

III. RECOMMENDATIONS

HMOs and physicians recognize that two-way communication is a critical part of maintaining an effective working relationship in the provision of quality, cost effective health care to HMO members. The following recommendations are intended to enhance the communication process.

A. Contracting Standards

Contracting standards should be developed for primary care physicians and each physician specialty. Such standards should be utilized in determining physician selection, retention and disaffiliation. The standards may include, but not be limited to the following: medical education; post-graduate medical training; board certification and eligibility; geographic location; office hours; hospital staff privileges; needs of HMO members for accessible and available medical care; number of members receiving care from the physician; results of patient satisfaction surveys; medical utilization factors based as much as practicable on objective data collection and interpretation; and the HMO's perception of a physician's ability to work collaboratively in a managed care environment. An HMO or physician group may change such standards from time to time.

 

B. Disclosure of Standards

Contracting standards should be disclosed to current and prospective participating physicians and CMS. Amendments to contracting standards should be communicated to participating physicians in a timely manner. Disclosure is subject to reasonable limitations to protect trade secret information.

 

C. Contracting Standards for Specialty Physicians

Contracting standards for specialty physicians should be developed by an HMO in consultation with physicians within that specialty and primary care physicians.

At the request of an HMO or physician group, CMS will identify specialist physicians from the community, academic institutions or specialty societies who will be available to consult in the development of contracting standards for specialist physicians.

 

D. Data Collection and Analysis

Specialty specific credentialing and contracting methodologies for data collection and analysis should be developed in consultation with physicians within that specialty and primary care physicians. Data systems for credentialing and contracting with primary care physicians should be developed in consultation with primary care physicians and appropriate specialist physicians.

 

E. Evaluation of Physicians

Each physician should be provided periodically (as appropriate for the nature and amount of data and the volume and scope of services provided by the physician for the HMO or physician group) with data regarding his/her performance within the HMO relative to stated criteria and to an appropriate group of comparable physicians. Upon presentation of such data, each physician should work cooperatively with the HMO or physician group to improve performance.

 

F. Specialist Department Chair

HMOs should consider utilizing a "department chair" or specialty consultant for each physician specialty. As determined appropriate by the Medical Director of the HMO or physician group the department chair or specialty consultant would act as an intermediary with specialty physicians to enhance communication and resolve issues relating to that specialty. The department chair or specialty consultant may also assist in the development of methodology for data collection and analysis and the interpretation of data regarding that specialty.

 

G. Disaffiliation

When making a decision to disaffiliate a physician, the most recent data available should be utilized and consideration given to such physician's response over time to data presented to him/her.

When disaffiliation occurs because of change in network size or composition, the disaffiliated physician should be provided with the reason, including the criteria and methodology utilized for disaffiliation decision.

When a physician chooses to disaffiliate, the physician should provide the HMO or physician group with the reason for such action.

IV. JOINT ACTIONS

CMS and the CHMOA will work collaboratively to undertake actions which will foster communication between physicians and HMOs and provide for non adversarial dispute resolution.

A. Colorado Medical Society Physician Consultant

HMO representatives will work with a physician "consultant" employed by CMS to develop "Physician Report Cards" and evaluate existing "Report Cards". Such consultant should have expertise in managed care and statistical analysis. Such "Report Cards" will consist of a set of criteria utilizing data whereby physician performance is evaluated. The "Report Card" development will include, but not be limited to the following:

1. Review of data collection and interpretation methodology;
2. Review of data interpretation techniques to ensure that it is understandable and usable for guiding change in physician behavior; and
3. Identify issues that are based on data.

CMS and CHMOA will work towards identifying and developing data collection and analysis methodologies to be utilized in connection with affiliation/disaffiliation of physicians.

A physician consultant or other representative of CMS will be available to advise its member physicians regarding physician "Report Cards" and disaffiliation actions.

CMS and CHMOA will jointly establish a program to review and endorse data collection and interpretation methodologies established for evaluation of physicians.

B. Mediation Process

CMS and the CHMOA under the auspices of the Colorado Bar Association shall develop and jointly adopt a procedure for implementing a mediation program for physicians involved in the affiliation/disaffiliation process. Such procedure shall be voluntary on the part of each physician and each HMO or physician group and invoked only after exhaustion of any internal appeal process available to a physician. CMS and the CHMOA will identify and arrange for training of a panel of mediators who will be available to participate in the mediation process.

CMS and the CHMOA will annually review the mediation process and jointly implement any needed changes to it.

Position and Concept Papers