Current through Register 1531, September 27, 2024
Notwithstanding any other provisions in
243 CMR
3.05 through
3.08,
a licensee may accept employment, practice, association for the purpose of
providing patient care, or privileges at a Health Maintenance Organization
(HMO), within the meaning of M.G.L. 176G, § 1, if the HMO has a Qualified
Patient Care Assessment Program which meets or exceeds the criteria set forth
below. The Board will consider such a Qualified Patient Care Assessment Program
a Risk Management Program within the meaning of M.G.L.
c. 112, § 5, requiring physicians to participate in risk management
programs as a condition of licensure. In addition, a Staff
Model HMO is not exempt from the requirements of
243
CMR 3.08.
(1)
Credentialing.
An HMO shall not appoint or hire, contract with, contract with any entity to
obtain the services of, associate with for the purposes of providing patient
care, or grant privileges to a licensee, unless the HMO first performs the
following evaluation of the licensee.
(a) The
following provisions apply with respect to a licensee who has been or within 90
days will be credentialed or re-credentialed pursuant to
243 CMR
3.05 by a licensed or state hospital within
Massachusetts.
1. Prior to the date on which
a licensee commences to practice medicine on behalf of an HMO:
a. In the case of a staff-model HMO, the HMO
shall request and the licensee shall provide to the HMO a copy of his or her
most recent application for an initial or renewal license issued by the
Board.
b. In the case of a
staff-model or a non-staff-model HMO, the HMO shall request and the
Massachusetts hospital where the licensee spends the greatest proportion of his
or her time (the "primary hospital") shall provide to the HMO written
confirmation that the licensee has been credentialed by the primary hospital
pursuant to
243 CMR
3.05. The written confirmation shall be
provided to the HMO within 30 days after the later of: receipt of the HMO's
request or, subject to
243 CMR
3.13(1)(a), the date on
which the licensee is credentialed or re-credentialed pursuant to
243 CMR
3.05 by the primary hospital. The written
confirmation shall describe each of the following known to the primary
hospital:
i. pending or closed healthcare
facility or public agency disciplinary actions against the licensee;
ii. alterations in privileges resulting,
directly or indirectly, from concerns about the licensee's professional
performance, judgment or clinical skills; and
iii. any other concerns relating to the
licensee's professional performance, judgment, clinical skills, or mental or
physical status, and any impairment of the licensee related to chemical
dependency.
c. The
licensee shall provide to the HMO a release and waiver to allow the HMO access
to any information in which the licensee has an interest that may be requested
by the HMO pursuant to 243 CMR 3.12(1)(a)3.
2. At least once every two years, the HMO
shall complete the following process. It shall be completed no later than 60
days after the licensee has been credentialed or re-credentialed pursuant to
243 CMR
3.05 by the primary hospital:
a. In the case of a staff-model HMO, the HMO
and the licensee shall complete the process described in 243 CMR
3.12(1)(a)1.a., if the process was not completed because the licensee first
associated with the HMO prior to July 1, 1987, or if the licensee's license has
been renewed since completion of that process.
b. In the case of a staff-model or a
non-staff-model HMO, the HMO shall complete the process described in 243 CMR
3.12(1)(a)1.b.
c. The licensee
shall provide to the HMO a release and waiver to allow the HMO access to any
information in which the licensee has an interest that may be requested by the
HMO pursuant to 243 CMR 3.12(1)(a)3.
3. If an HMO obtains adverse information
regarding the licensee pursuant to 243 CMR 3.12(1)(a)1. or 2. or 243 CMR
3.12(1)(b) or (c), the HMO may request in writing and the primary hospital
shall provide to the HMO within 30 days, in accordance with M.G.L. c. 111,
§§ 204 and 205 and M.G.L. c. 111, § 70E, such additional
information as the HMO deems necessary to complete its credentialing of the
licensee (with regard to information about non-members of the HMO, the
identities of particular patients may be redacted). The HMO shall reimburse the
primary hospital for the reasonable costs of providing information pursuant to
243 CMR 3.12(1)(a)3.
(b)
A licensee who has not been credentialed by a licensed or state hospital within
Massachusetts pursuant to
243 CMR
3.05 shall be credentialed by the HMO
pursuant to
243 CMR
3.05 prior to the date on which the licensee
commences to practice medicine on behalf of the HMO, and biennially
thereafter.
(c) The HMO shall
perform an initial and biennial credentialing evaluation of the licensee, based
on the information obtained pursuant to 243 CMR 3.12(1)(a) and (b), as
applicable, and based on information developed by the HMO's Patient Care
Assessment program. The evaluation shall include assessment of the licensee's
professional performance, judgment and clinical skills.
(d) Based on information received or
developed by the HMO, the HMO shall provide in writing to any health care
facility credentialing a licensee, upon written request by that facility, an
assessment of the licensee's clinical skills, information regarding
disciplinary actions and malpractice litigation, and other relevant information
related to the licensee's competence to practice medicine. The HMO may
summarize information obtained pursuant to 243 CMR 3.12(1)(a)3. in order to
fulfill the credentialing requirements of
243 CMR 3.01,
but it shall not re-disclose such information without the prior written consent
of the primary hospital from which it was received.
(2)
Structure and Required
Functions. The HMO's Qualified Patient Care Assessment Program may
function as a system of "peer review," otherwise consistent with M.G.L. c. 111,
§ 204, shall be in writing, shall be submitted to the Board, and shall
include the following functions:
(a) Systems
to identify, analyze and resolve patient risks, as they occur in a hospital or
ambulatory setting if under the HMO's ownership or control, including at least
one mechanism that identifies patient care problems which might indicate
incompetency of a licensee or conduct inconsistent or harmful to good patient
care.
(b) Systems to identify,
analyze and resolve patient grievances.
(c) The designation of personnel, including
licensees, and/or committees to investigate, analyze and resolve patient risks
and grievances and to recommend changes in policies, procedures and personnel
as necessary. The analysis of patient risks and grievances shall include, at a
minimum, a regular review for the purposes of identifying trends or patterns as
to time, place and recurrent involvement of a licensee. Such personnel shall
have unrestricted access to all patient records.
(d) The designation of personnel to
coordinate the identification, analysis and resolution of patient risks,
complaints and grievances and to assure that the Qualified Patient Care
Assessment Program functions on an on-going basis.
(e) The delineation of lines of authority and
communication among all personnel and committees responsible for the
administration and functions of the Qualified Patient Care Assessment Program,
including the roles and responsibilities of the medical peer review
committee(s) and the governing body of the HMO.
(f) Procedures for educating all employees
and licensees affiliated with the HMO, and involved in patient care, in the
operation of the Qualified Patient Care Assessment Program and in their
responsibilities and duties therein, including but not limited to training
regarding responsibilities pursuant to M.G.L. c. 112, § 5F.
(g) The establishment of criteria to
determine whether disciplinary action against a licensee is necessary as
indicated by the analysis of patient care risks, complaints and grievances, and
the creation of a medical peer review committee to make such determination in
connection with the skills, competence, judgment and performance of
licensee.
(h) Provisions to grant
the Board and the Division of Insurance with access and audit authority over
Qualified Patient Care Assessment Program information and records during normal
business hours.
(i) Provisions to
allow administration of a reasonable and comprehensive evaluation of a
licensee's clinical skills, competence and judgment, upon request of and for
filing with the
Board.