Colorado Medical Society

Report of: Council on Practice Environment

Subject: Progress Report

Referred to: Reference Committee on Health Affairs

recommendations from the POLICY forum, Respectfully submitted for adoption by the House:

1. Development of Standardized Contract language to minimize the potential for plan misrepresentation, legitimate misunderstandings between plans and physicians over what should be standard procedural and contractual matters, and to provide for the transparent understanding by physicians of any departure from standard language—exceptions, codicils, caveats, or preemptions. The concept of a standardized contract (see COPE-1, Attachment 1) should be vetted through physicians and physician-driven organizations to determine the feasibility of introduction of legislation in the 2006 General Assembly.

2. Establishment of separate work groups to study/evaluate the pay-for-performance programs being developed by all payers.

a. The work groups will be based on physician experience and expertise with Evidenced-Based Medicine (EBM) principles and systems, as well as unique familiarities with specific plans systems. The Forum will instruct the work groups to urge all health plans to put a greater emphasis on preventive care in the development of these programs.

3. Establishment of a separate work group to develop recommendations for resolution of the Par/Non-Par issue. Under the current law, when a patient receives care in accordance with the health plan’s provisions at a network facility and is treated by a physician who is not contracted with the patient’s health plan, the health plan is required to hold the patient harmless of any financial responsibility and pay the non-participating physician 100% of his/her billed charges. The issue was reviewed during the 2005 General Assembly and CMS provided testimony (see COPE-1, Attachment 2 for the report from the Council on Legislation’s special work group). The legislature will be looking for these interim committees to provide an alternative approach that is acceptable to the non-participating hospital-based physicians and the health plans, that also provides some protection for the patients.

4. The Forum also recommended that CMS urge health plans in Colorado to have local physician advisory boards, and to develop common criteria concerning the issues that should be routinely presented to these advisory boards for comment.

RECOMMENDATIONS FROM COPE RESPECTIVELY SUBMITTED FOR ADOPTION BY THE HOUSE:

1. CMS through COPE should continue to work with county and local specialty societies to develop data for the US Department of Justice on the proposed acquisition of PacifiCare by United.

2. CMS through COPE should continue the dialogue between CMS, county and specialty societies with United on the Premium Designation Program.

3. CMS through COPE should develop an operational strategy to use when other programs that resemble pay-for-performance arise.”