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:
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Health plans that contract with selected physicians to furnish care
should utilize selection criteria based primarily on professional
competence and quality care.
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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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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.
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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 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 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.
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The WSMA supports physician-directed health plans which are intended to
provide willing physicians access to the market.
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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).
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The WSMA endorses the concept of Medical Savings Accounts (MSAs) and
promotes evaluation of their acceptance and efficacy in the market.
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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-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