Selective Contracting
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Those health delivery or financing systems that contract with selected
physicians to furnish care should utilize selection criteria based
primarily on professional competence and quality care. Any economic
criteria used in selective contracting should have a demonstrated
relationship to the quality and appropriateness of care and to
professional competency.
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Health plans that contract with selected providers should have an
established mechanism by which any provider willing to abide by terms of
the plan contract could appeal a decision to deny the provider's
application for participation in the plan.
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Health plans or networks should provide public notice within their
geographic service areas when applications for participation are being
accepted.
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Physicians should have the right to apply to any health care plan or
network in which they desire to participate and to have that application
judged on the basis of objective criteria that are available to both
applicants and enrollees.
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Selective contracting decisions made by any health care delivery or
financing system should be based on an evaluation of multiple criteria
related to professional competency, quality of care, and the
appropriateness by which medical services are provided. In general, no
single criterion should provide the sole basis for selecting, retaining,
or excluding a physician from a health care delivery or financing
system.
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Prior to initiation of actions leading to termination of a physician's
participation contract "for cause," the physician should be given notice
specifying the grounds for termination, an opportunity for discussion,
and an opportunity to initiate complete remedial activities, except in
cases where harm to patients is imminent or an action by a state medical
board or other government agency effectively limits the physician's
ability to practice medicine.
(CPA Rpt D, A-93) (Reaffirmed A-23)
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Abbreviations for House of Delegates report origination:
EC – Executive Committee; BT – Board of Trustees; CPA – Council on
Professional Affairs; JC – Judicial Council; CHS – Community and Health
Services