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Better patient care proposed by Blue Cross and AMA

A group of insurers and doctors has stopped fighting to collaborate on 10 recommendations for how physicians and health insurance plans can better work together to improve patient care.

"Most of us believe that managed health care has taken a wrong turn when it comes to physician relations."

The guidelines, developed by the Blue Cross and Blue Shield Association (BCBS) with help from the American Medical Association (AMA), address problems that have long led to animosity between physicians and health plans. These include the "gag rules" that some health insurers use to bar doctors from discussing with patients those expensive tests and treatments that the health plans might not cover.

"Most of us believe that managed health care has taken a wrong turn when it comes to physician relations," says Scott P. Serota, BCBS president and chief executive officer. "In many cases, much of the tension between managed care companies and physicians over the last decade can be attributed to poor communication."

The guidelines are not binding on any physicians belonging to the AMA or the 45 independent, locally operated BCBS plans that provide health care to more than 80 million Americans. However, the AMA will distribute the guidelines to its members. "We hope [the guidelines] can be used in our mutual efforts to help improve patient care as well as the working relationship between physicians and Blue plans," says Dr. D. Ted Lewers, chairperson of the AMA Board of Trustees.

Guidelines for health plans and network physicians in health plans

1. Health plans should involve network physician representatives in clinically-oriented   decision-making committees.

2. Network physician representatives should have input into health plans credentialing and recredentialing processes. Network physicians should have access to fair and objective appeals for contract terminations.

3. All of the specialties participating in a clinical process should be involved in the writing of clinical practice and disease management guidelines.

4. While health plans make coverage decisions, network physicians must be able to discuss all treatment alternatives with their patients to enable them to make informed decisions.

5. Members in a health plan and their authorized representatives should have access to timely appeals processes. Network physicians serving in the appeals process should have experience in the type of care under dispute.

6. Peer review protections should extend to all sites of care.

7. Network physician representatives should be involved in the design of clinical data collection systems and the interpretation of that data. All network physicians should receive periodic performance and utilization data appropriate to their contractual relationship with their plan (e.g., HMO vs. PPO participation).

8. Network physician representatives should be involved in developing clinical quality assessment and improvement data.

9. All network physicians should be informed of the identity of their representatives serving on clinically oriented health plan committees. A mechanism should be in place for network physicians to communicate their concerns to their representatives.

10. Health plans should provide appropriate indemnity or insurance coverage to network physician representatives involved in clinically oriented decision-making committees.

Source: Blue Cross and Blue Shield Association

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