SFMS/CMA has recently become aware that a broad "indemnification" clause in the UnitedHealth Military & Veterans Services (UMVS) TRICARE provider contracts is causing some professional liability carriers to exclude coverage for services provided to TRICARE beneficiaries.

Although California's Knox Keene Act prohibits indemnification clauses in physician contracts, the contract in question is governed by federal law. Indemnification clauses are not uncommon, and usually are used to restrict liability in the case of willful misconduct. The clause in the UMVS contract, however, is so broad that at least two professional liability carriers have indicated that they would not defend or indemnify the physicians in the event of a claim brought by a TRICARE beneficiary.

SFMS/CMA has escalated this issue to high level contacts at UMVS. We will provide additional information as it becomes available. In the meantime, physicians are urged to reach out to their liability carriers to determine if they are covered when treating TRICARE patients.

SFMS members with reimbursement questions can contact our Member Helpline for one-on-one assistance at (800) 786-4262.

Physician-led accountable care organizations (ACOs) could have more opportunities to create savings in patient care with a little help from health insurers, a leading health reform expert said Wednesday.

Doctor-centric ACOs can do a better job at controlling costs than hospital-led organizations, Paul Ginsburg, PhD, president of the Center for Studying Health System Change, said at an ACO summit hosted by America's Health Insurance Plans.

Entrepreneurial insurance companies can offer loans to provider groups to expand or re-engineer to become ACOs through Medicare or commercial payers. Others can create innovative programs that have physicians take additional risk to improve outcomes and lower costs for patients.

"I think physician-led ACOs inherently make markets more competitive because they have an opportunity to shift patients toward higher-value hospitals," Ginsburg said. "It means that a hospital market that might not have large competition going, all of a sudden, if there's a physician-led ACO, those hospitals have to compete on price for the allegiance of those physician-led ACOs."

Unlike in hospital-led ACOs, doctor-led ACOs aren't compromised financially by reducing hospital admissions and emergency department visits, he pointed out.

In fact, physician-led ACOs already outnumber their hospital counterparts, the latest data from the Centers for Medicare and Medicaid Services (CMS) show. However, doctor-organized groups typically treat fewer patients than those formed by hospitals.

Charlie Baker, former Secretary of Health and Human Services Secretary in Massachusetts, noted that nearly every shared-risk model in Medicare Advantage is with physician groups and not hospitals, he says, because insurers know that's how to save money.

Baker said he believes there will be more growth in small providers pooling resources to become ACOs. "My big fear is they're starting behind the larger players, way behind," Baker said.

Physician groups are still skeptical of quality metrics used to determine the shared savings in ACOs, Ginsburg said.

However, CMS rules on ACOs favor hospital-led organizations. "The CMS rules are making it exceedingly difficult for an independent physician group to form an ACO," Baker said.

To that point, Ginsburg noted the federal government can play a larger role in facilitating physician-led ACOs.

"I think of the federal support for the HMOs in the 1970s as to whether it'd be feasible to have the federal government support the development of physician organizations as an investment for viable markets in the future," Ginsburg said.

No matter what happens, whatever strategy emerges to control costs must tackle provider payments—an area public and private payers seem to be in agreement on.

Source: MedPage Today, May 15, 2013.

SFMS and CMA have joined an unprecedented coalition of physicians, dentists, health care workers and hospitals working to stop the 10% Medi-Cal reimbursement rate cut.

The We Care for California coalition was borne of an effort to build a strong coalition of diverse organizations fighting to ensure that California’s health care system doesn’t continue to get short changed. So often in the past, health care advocates have become divided in their efforts, so focused on individual organizational interests, that the collective strength is weakened. We Care for California intends to stand undivided in using the coalition’s collective influence in defense of health care.

The coalition’s first major effort is to ensure that two CMA-sponsored bills—SB 640 (Lara) and AB 900 (Alejo)—are passed by the Legislature and signed by Governor Brown. Both bills, sponsored by CMA, would stop the 10 percent Medi-Cal rate cut.

Join “We Care for California” in Sacramento on Tuesday, June 4 from 11 am to 4 pm

to call on State Legislators and the Governor to stop the $1 billion reduction in provider rates in the Medi-Cal program. SFMS/CMA physicians will stand with nurses, dentists, and other health care providers as well as patient and consumer groups to advocate for the support of SB 640 and AB 900.

This will be the largest health care gathering ever at the state Capitol, and will send a powerful message that we expect our elected leaders to stand up for quality care in California.

The goal is to bring 10,000 health care providers together from across the state participate.

Buses will be available to transport anyone who wants to participate from hospitals around the state to the Capitol building in Sacramento at no charge to the participant. If you are interested in attending the event, please register at www.wecareforca.org to reserve a seat on the bus nearest you.

Click here for detailed event and RSVP information.

California’s trial attorneys launched an all-out assault on California's historic tort reform law, which since 1975 has helped keep malpractice premiums in-check and ensured that California’s patients have access to affordable health care.

On May 2, 2013, a coalition—including the Consumer Attorneys of California and the trial lawyer-funded Consumer Watchdog group—announced intentions to seek to overturn California's landmark Medical Injury Compensation Reform Act (MICRA) through a ballot initiative. The group has until September to submit a proposed initiative to qualify for the November 2014 general election ballot.

If successful, the trial attorney’s efforts will cause malpractice rates to skyrocket, and recreate the same conditions that threatened to throw California’s health care system into crisis during the early 1970s. Prior to MICRA, out-of-control medical liability costs were forcing community clinics, health centers, physicians and other health care providers out of practice.

California’s MICRA has been a national success story with broad public support and has safeguarded both patients and our health care delivery system for decades. Risky reforms like the ones being threatened by the trial lawyers would severely impede our state’s ability to provide health care to the poorest and most vulnerable patients. At a time when we are trying to implement federal health care reform and provide access to health care to all Californians, this is the worst possible overreach at the worst possible time.

 

"The threat of a ballot measure is nothing more than a money grab by trial lawyers," says CMA President Paul R. Phinney, MD. "And one that that will come at the expense of higher health costs for all patients and decreased access for patients and clinics already struggling to keep their doors open. We cannot and will not let that happen."

Click here for more information on MICRA, and what you can do to help in the fight.

The California Medical Association (CMA), together with other amici, has asked the California Supreme Court to depublish an appellate court opinion that thwarts the long-standing definition of "professional negligence" in California's Medical Injury Compensation Reform Act (MICRA). The ruling, if allowed to stand as precedent for future cases, could be misused to undermine the goals of MICRA and adversely affect the entirety of the health care system and safety net in California.

In Flores vs. Presbyterian Intercommunity Hospital, a hospital inpatient sued for injuries she allegedly sustained from a fall when her hospital bed rail collapsed. The appeals court ruled that the negligence did not occur in the rendering of professional services and as such was subject to the two-year statute of limitations for ordinary negligence rather than the one-year statute of limitations for professional negligence.

CMA, California Dental Association, and California Hospital Association filed a joint amicus letter urging the Supreme Court to depublish the Court of Appeal’s opinion on the grounds that the opinion was wrongly decided, having been based on a poor factual record and consideration of less than all the pertinent authority.

CMA’s letter points out that under the long-standing definitions in MICRA, professional negligence includes any act or omission by a health care provider in the rendering of professional services for which the provider is licensed. Despite this clear definition and the fact that the provision and maintenance of safe hospital beds is a service for which hospitals are licensed, the Court of Appeal’s opinion failed to even address the pertinent licensing laws and regulations.

CMA and the other amici urged depublication because this wrongly decided opinion will not provide meaningful guidance in future cases and obscures the definition of what constitutes professional negligence under MICRA.

MICRA, California’s landmark professional liability reforms, have for nearly 40 years fairly compensated injured parties while protecting access to care for Californians.

Click here for more information on MICRA.