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1. CMA Urges Physicians to Correct Data Used
by Payors to Grade their Performance
In the last three weeks, some 20,000 California physicians received letters from the California Physician Performance Initiative (CPPI). These letters contain raw and relative performance scores for physicians on 15 quality measures based on claims data from Medicare and United Health, Blue Cross, and Blue Shield PPOs. The
letters do not contain the underlying data.
CMA has serious concerns about the accuracy and integrity of the data used to establish these scores and the potential use of these scores or these metrics by payors to do pay-for-performance or create tiered networks. In order to address CMA concerns and to improve the quality of the data, CPPI has created a reconsideration process that physicians should use to verify the data.
CMA urges all physicians to request their data from CPPI and verify its accuracy.
In checking the data, physicians should check whether CPPI correctly listed the patient name, physician name, and specialty, and whether or not the physician performed the procedure. If you did not perform the procedure, we encourage you to explain why, and, if applicable, why the particular metric does not make sense as a measurement of the quality of care you provided to your patient.
We understand that this may be a time-consuming process, but it is critical for physicians to take the time to verify their data. If you do not raise concerns now, payors will use this data in the future to adjust your reimbursements and change the flow of patients to your practice.
CMA also asks that you share any corrections or concerns about the data with us. (Please do not send any patient information covered by HIPAA.)
Step by step instructions on obtaining and reviewing your patient data is available here.
Once you have completed the reconsideration process, please also take CMA’s online survey to tell us what, if anything, was wrong about your performance scores. This step is important to ensure that CMA has the information needed to advocate on your behalf.
Contact: CMA Member Help Line, 800/786-4CMA (4262).
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2. Insurers Updating Contracts to
Comply with Language Access Regs
CMA has updated ON-CALL document #0813, “Language Interpreters,” to address various new health plan contract amendments related to the Language Assistance Program (LAP) regulations that will take effect next year. Because the law leaves it up to each insurer to establish its own LAP standards and procedures, physicians are understandably concerned about what these regulations mean to their practices. (ON-CALL documents are free to members at the members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in the CMA Bookstore.)
The regulations, recently adopted by the Department of Managed Health Care (DMHC) and the Department of Insurance (DOI), require health insurance companies to provide free interpretation and translation services in “threshold languages” to enrollees with limited English proficiency (LEP). The DMHC regulations take effect on January 1, 2009, and the DOI regulations April 1.
The regulations place the financial responsibility for compliance on the insurers, except when delegated financial responsibility has been negotiated separately. Previously proposed regulations would have placed the burden on physicians to provide these services.
Physicians’ obligations will vary by insurer, but in general physicians will be required to: inform patients of the availability of translation and interpretation assistance at the point of service; document when and if LEP patients refuse language assistance; and complete provider language capability disclosure forms so that the health plans can assess the LAP needs of their enrollees.
As each insurer’s LAP standards may vary, it is critical that contracted physicians are provided with adequate information about those standards. Some plans, such as Blue Cross, have already forwarded the details of their programs to physicians through contract amendments and updated program manuals. Other plans, such as United Healthcare, have merely required that physicians comply with their LAP without disclosing the underlying details. CMA believes this is insufficient and urges physicians faced with the latter scenario to contact the plan so that they understand their obligations. CMA has already discussed this issue with United, and the insurer has agreed to provide physicians with additional detail about its language assistance program.
CMA is closely monitoring the situation and encourages physicians to report any burdensome requirements to CMA.
Contact: CMA’s Reimbursement Helpline 888/401-5911 or drice@cmanet.org.
3. Blue Cross Removes More Onerous
Provisions from Physician Contracts
As we reported in Alert last month, Blue Cross recently agreed to remove the most problematic provisions from its physician contracts. CMA is pleased to report that the insurer has also agreed to remove onerous provisions from the Prudent Buyer contract amendment issued earlier this year.
Among other things, the amendment stated that physicians would be subject to contract termination and legal action if physicians disclosed or discussed the terms of the amendment with any third party, which CMA interpreted to include even their own attorneys or business managers. The revised contract now simply states that physicians must keep the terms of the contract confidential. The penalties for disclosure have been removed.
The amendment also prevented physicians from renegotiating or terminating their agreements at any time during the three-year contract term. The revised contract now requires Blue Cross to give physicians 90 days prior notice of a material change to the contract and allows physicians to terminate the agreement prior to the change becoming effective, as required by California law.
Unfortunately, the amendment continues to prohibit physicians from closing their practice to new Blue Cross patients unless they also stop taking new patients from all other contracted health plans. CMA believes this provision is inconsistent with California law, which prohibits health plans from forcing physician to accept additional patients if, in the physician’s reasonable professional judgment, accepting additional patients would endanger patients’ access to, or continuity of care. CMA will continue to advocate for its removal.
These and other problematic provisions will not be included in new and renewing physician contracts, and Blue Cross has informed CMA that it will not enforce these provisions in existing contracts.
HMO Nonpayment for Emergency Services: On November 5, the California Supreme Court heard Prospect Medical Group v. Northridge Emergency Medical Group, a case determining whether current California law prohibits physicians from billing patients for the portion of their bill for emergency services which HMOs refuse to pay. CMA strongly believes that current law has no such prohibition and submitted an amicus brief in this case to that effect.
CMA attorneys and physician leaders were on hand for the oral arguments, which did not reveal which way the court was leaning. The court will issue its ruling within 90 days of the hearing.
Physician Liability: On November 3, the United States Supreme Court heard oral arguments in Wyeth v. Levine, a case dealing with whether federal law preempts efforts by states to require stronger warnings on products. In this case, a Vermont musician had her arm amputated after she was injected by an IV push with an antinausea drug. The injection struck an artery and caused gangrene.
CMA filed an amicus brief in the case, arguing that federal preemption of failure-to-warn claims would jeopardize patient safety and expose physicians to new and unwarranted liability for pharmaceutical companies’ failures to provide them and their patients with adequate warnings. A ruling is not expected for several months.
5.
Gov. Proposes Cuts and Taxes to Address $11.2B Shortfall
Governor Schwarzenegger announced last week a special legislative session to deal with the $11.2 billion budget shortfall facing California for the current fiscal year. The Governor also proposed cutting $4.5 billion from the current budget, including $142 million from Medi-Cal. However, due to CMA’s successful lawsuit that prevents the state from cutting Medi-Cal reimbursement rates to physicians and other providers, the Governor’s current proposal scores savings by modifying eligibility requirements and eliminating benefits not required by federal law, including adult dental and psychology services.
The Governor’s proposal also includes $4.7 billion in new tax revenue.
Negotiations on California’s ongoing budget problems are expected to continue throughout the next legislative session.
Although a few candidate races remain too close to call, the results from the 2008 California election already look positive for California physicians. CMA-opposed Proposition 4, a parental notification measure that would have created onerous reporting requirements for physicians, was narrowly defeated. CMA-supported Proposition 3 passed by a wide margin, steering much-needed additional resources to children’s hospitals.
On the candidate side, CALPAC built upon its success in the primary elections, continuing its new focus on Independent Expenditures (IEs) to aggressively support pro-physician candidates. Because IEs are not done in coordination with the candidates, they are free from the normal contribution limits and can amplify our ability to communicate CMA’s perspective to voters.
In four of the six races in which CALPAC did IEs, CALPAC-supported candidates have either won outright or are winning. CALPAC also continued its support of many successfully elected pro-physician candidates through more traditional direct contributions.
More than a dozen physicians representing CMA and the California Psychiatric Association testified at a public hearing on October 23 in opposition to a proposal that would expand the scope of practice of psychologists and potentially all other health care practitioners working in licensed health care facilities. The regulations—proposed in July by the California Department of Public Health (CDPH) and intended to clarify state law as it applies to medical staff membership and privileges for psychologists—would weaken medical staff self-governance rights and could be broadly interpreted to allow unqualified health care professionals to carry out the duties of a physician or surgeon.
CMA also submitted written testimony explaining the association’s legal and clinical opposition to the regulations. “As a matter of quality of care and law, physicians must be responsible for the medical care of patients admitted to hospitals,” wrote CMA. “By obscuring the distinction between those responsibilities managed by physicians and those managed by other health care providers, these proposed regulations will make it more difficult to determine when a practitioner is practicing outside the bounds of his or her licensure.”
CMA is working with a number of different stakeholders to oppose the proposed regulations, including the California Psychiatric Association, the Medical Board of California, the American Psychiatric Association, the American Medical Association, and the American Academy of Otolaryngology.
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