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Physician Health Plan Participation

Physician-Health Plan Relations

The WSMA has established policy on physician access to the marketplace, consumer choice, and physician-health plan relations including disclosure and due process issues associated with selective contracting as follows:

  • Health plans 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.
  • Consumers in Washington state should not be offered or enrolled in any health care insurance plan before a health insurance carrier can guarantee the consumer that it has the ability to deliver the product it is marketing, including having the appropriate physicians already under contract who can provide the services covered in the benefits package.
  • 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.
  • Health plans or networks should provide public notice within their geographic service areas when applications for participation are being accepted.
  • Physicians should have the right to apply to any health 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.
  • 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
  • Prior to initiation of actions leading to termination of a physician's participation in a 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 eminent or an action by a state medical board or government agency effectively limits the physician's ability to practice medicine.
  • The WSMA supports physician-directed health plans which are intended to provide willing physicians access to the market.
  • The WSMA supports the ability of physicians to effectively aggregate and participate in the market (i.e., repeal of Certificate of Need laws and creation of antitrust relief).
  • The WSMA endorses the concept of Medical Savings Accounts (MSAs) and promotes evaluation of their acceptance and efficacy in the market.
  • The WSMA opposes legislation, ballot initiatives or regulations that would mandate inclusion of "any willing provider" or all classes of providers in health plans or networks. (BT Rpt H, A-96) (Reaffirmed A-17)

Return to the WSMA Policy Compendium index

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

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