Ama Policy

The Critical Role of Physicians in Health Plans and Integrated Delivery Systems H-285.931

U.R. Criteria

Our AMA adopts the following organizational principles for physician involvement in health plans and integrated delivery systems (IDS):

(1) Practicing physicians participating in a health plan/IDS must:

(a) be involved in the selection and removal of their leaders who are involved in governance or who serve on a council of advisors to the governing body or management;

(b) be involved in the development of credentialing criteria, utilization management criteria, clinical practice guidelines, medical review criteria, and continuous quality improvement, and their leaders must be involved in the approval of these processes;

(c)be accountable to their peers for professional decisions based on accepted standards of care and evidence-based medicine;

(d) be involved in development of criteria used by the health plan in determining medical necessity and coverage decisions; and

(e) have access to a due process system.

(2) Representatives of the practicing physicians in a health plan/IDS must be the decision-makers in the credentialing and recredentialing process.

(3) To maximize the opportunity for clinical integration and improvement in patient care, all of the specialties participating in a clinical process must be involved in the development of clinical practice guidelines and disease management protocols.

(4) A health plan/IDS has the right to make coverage decisions, but practicing physicians participating in the health plan/IDS must be able to discuss treatment alternatives with their patients to enable them to make informed decisions.

(5) Practicing physicians and patients of a health plan/IDS should have access to a timely, expeditious internal appeals process. Physicians serving on an appeals panel should be practicing participants of the health plan/IDS, and they must have experience in the care under dispute. If the internal appeal is denied, a plan member should be able to appeal the medical necessity determination or coverage decision to an independent review organization.

(6) The quality assessment process and peer review protections must extend to all sites of care, e.g., hospital, office, long-term care and home health care.

(7) Representatives of the practicing physicians of a health plan/IDS must be involved in the design of the data collection systems and interpretation of the data so produced, to ensure that the information will be beneficial to physicians in their daily practice. All practicing physicians should receive appropriate, periodic, and comparative performance and utilization data.

(8) To maximize the opportunity for improvement, practicing physicians who are involved in continuous quality improvement activities must have access to skilled resource people and information management systems that provide information on clinical performance, patient satisfaction, and health status. There must be physician/manager teams to identify, improve and document cost/quality relationships that demonstrate value.

(9) Physician representatives/leaders must communicate key policies and procedures to the practicing physicians who participate in the health plan/IDS. Participating physicians must have an identified process to access their physician representative.

(10) Consideration should be given to compensating physician leaders/representatives involved in governance and management for their time away from practice.

Our AMA aggressively advocates to private health care accreditation organizations the incorporation of the organizational principles for physician involvement into their standards for health plans, networks and integrated delivery systems.


Policy Timeline

Res. 706, I-98 Reaffirmation A-99 Reaffirmation A-07 Reaffirmed: Res. 709, A-12 Reaffirmed: Res. 814, I-13