I was among more than 100 voting medical staff members from around the country attending the AMA Organized Medical Staff Section (OMSS) meeting in Dallas in early November. All OMSS resolutions and deliberations ultimately go to the full AMA House of Delegates for debate and ratification on issues that largely affect medical staff members and organizations.

Some physicians feel that the AMA has become irrelevant and powerless. However, I disagree and can only point out that the AMA is still the only physician organization that speaks for all physicians — the “House of Medicine”. It is our only effective voice to influence JCAHO, Congress, and CMS. I will summarize the more important issues that we dealt with:

Pay-for-Performance
– The AMA has approved comprehensive Pay-for-Performance (PFP) Principles and Guidelines. The AMA is actively opposing private payer, congressional, or Centers for Medicare and Medicaid Services (CMS) PFP initiatives that are not in accord with the AMA PFP Guidelines.

The AMA recognizes that physician pay-for-performance (PFP) programs that are designed primarily to improve the effectiveness and safety of patient care may serve as a positive force in our healthcare system. Fair and ethical PFP programs are patient-centered and link evidence-based performance measures to financial incentives. Such PFP programs are in alignment with the following five AMA principles, which I’ve summarized here. (If anyone would like a copy of the complete report, please email me):

(1) Ensure quality of care - Fair and ethical PFP programs are committed to improved patient care as their most important mission. Evidence-based quality of care measures, created by physicians across appropriate specialties, are the measures used in the programs. Variations in an individual patient care regimen are permitted based on a physician’s sound clinical judgment and should not adversely affect PFP program rewards.

(2) Foster the patient/physician relationship – Fair and ethical PFP programs support the patient/physician relationship and overcome obstacles to physicians treating patients, regardless of patients’ health conditions, ethnicity, economic circumstances, demographics, or treatment compliance patterns.

(3) Offer voluntary physician participation – Fair and ethical PFP programs offer voluntary physician participation, and do not undermine the economic viability of non-participating physician practices. These programs support participation by physicians in all practice settings by minimizing potential financial and technological barriers, including costs of start-up.

(4) Use accurate data and fair reporting – Fair and ethical PFP programs use accurate data and scientifically valid analytical methods. Physicians are allowed to review, comment and appeal results prior to the use of the results for programmatic reasons and any type of reporting.

(5) Provide fair and equitable program incentives? – Fair and ethical PFP programs provide new funds for positive incentives to physicians for their participation, progressive quality improvement, or attainment of goals within the program. The eligibility criteria for the incentives are fully explained to participating physicians. These programs support the goal of quality improvement across all participating physicians.

Principle five is especially important since it calls for “new funds” for PFP programs. Most currently proposed PFP programs simply hold back funds and re-distribute them to “winners” in the PFP game.

AMA Conflict of Interest Guidelines
– The AMA has approved comprehensive Conflict of Interest Guidelines for Medical Staffs to help us set policy for our respective organizations. During this discussion, it was stressed that medical staffs should retain independent medical staff counsel when drafting their bylaws and policies rather than relying on hospital attorneys.

Because of these recommendations, your elected medical staff leaders have commissioned a complete review of our Bylaws and Rules by an AMA attorney who specializes in medical staff law. Elizabeth A. Snelson, Esq., a former CMA attorney, will conduct this review and is expected to submit results to us by January. As your representatives, we are committed to ensure that our Bylaws conform to good practice, meet regulatory requirements, and conform to the new California law (SB 1325) mandating an independent and autonomous medical staff.

JCAHO Standards regarding: Medical Staff Responsibilities
- JCAHO Standard MS 1.20 mandates that the medical staff be responsible for the following duties:

Application, reapplication, credentialing and privileging standards;
Fair hearing and appeal process;
Selection, election and removal of medical staff officers;
Clinical criteria and standards which manage quality assurance, utilization review;
Structure of the medical staff organization;
Rules and regulations that affect the entire medical staff.

The AMA has petitioned JCAHO to enforce hospital compliance with this standard and to require that these duties remain an integral part of the medical staff bylaws.

Balance Billing of Medicare Patients
- The AMA and OMSS are concerned about the inadequacy of medical reimbursement for physicians and hospitals. The AMA will seek federal legislation allowing physicians and hospitals to balance bill Medicare patients.

The policy adopted asks the AMA to:

(1) prepare federal legislation to allow physicians to balance bill regardless of the payer and seek sponsors for this in the U.S. Congress, (2) support federal and state legislation and regulation that permits physicians and hospitals to cancel or reduce copayments for hardship cases without change in fee schedules, and (3) make balance billing a high priority. Obviously, this legislation will be controversial if it is introduced.

Insurance Company Report Cards
- The AMA plans to study and develop the concept of an insurance company report card which measures, at a minimum, performance standards for patient satisfaction, physician satisfaction, hospital satisfaction, use of rapid electronic payment, and medical-loss ratio. Interestingly, the CMA has published a report comparing medical-loss ratios (the amount paid for administration of the insurance company instead of for patient care) for insurance companies in California for many years.

Medical Staff Involvement in Hiring and Evaluating Hospital Medical Directors
- The AMA is developing standards (for JCAHO) to allow and encourage medical staffs to review performance of hospital medical directors periodically and to have the ability to review and influence the hiring of new medical director candidates. In our case, the office of “chief of staff” is, in effect, a medical director since the office is an appointed hospital position, not an elected position.

Medical Staff Governance Principles
- California’s recently enacted Senate Bill 1325 has become the model for all other state medical associations to develop and introduce similar legislation. Senate Bill 1325, as you may remember, established the principles that the medical staff is an independent and autonomous organization, equal in legal status to the hospital and governing board. The AMA model legislation will have the following principles (basically taken from SB 1325):

Medical staffs should be protected from board interference regarding specific medical staff activities, such as:

(1) Initiating, developing and adopting medical staff bylaws, rules and regulations (2) Selecting and removing medical staff officers; (3) Assessing medical staff dues and utilizing the medical staff dues as appropriate for the purposes of the medical staff; (4) The ability to retain and be represented by independent legal counsel at the expense of the medical staff; (5) Establishing, in medical staff bylaws, rules or regulations, criteria and standards for medical staff membership and privileges, and for enforcing those criteria and standards; (6) Establishing in medical staff bylaws, rules or regulations, clinical criteria and standards to oversee and manage quality assurance, utilization review and other medical staff activities.

The world of medical staff governance is a special place where most of us never venture. Since I must go there, I’m glad to bring back a few glimpses of this world and hope that each of you will take a few minutes to read what’s happening. That way we’ll be on the same page based on facts instead of coffee break rumors. As always, please don’t hesitate to contact me with your ideas or questions at kgarman@stanford.edu.

Hope you all have a wonderful holiday season!