285. Peer Review
285.993 Colorado Professional Peer Review Act Sunset
Colorado Professional Peer Review Act Sunset
Guiding principles for peer review sunset:
CMS believes that statutory changes to CPRA should strengthen professional review processes that:
- Improve patient safety and contribute to ongoing education in the health care system
- Improve provider accountability
- Are fair
- Provide for consistency in data collection
- Contain safeguards to minimize the potential for abuse
- Minimize adversarial situations
- Promote teamwork among stakeholders
Recommendations
- Schedule sunset for five years in order to create momentum for continued work by physicians and hospitals on consistency and predictability of peer review processes.
- Harmonize CPRA with federal peer review law to minimize conflicts.
- Clarify the definition of records to eliminate disputes about what is and is not admissible in court.
- Expand the definition of entities that qualify as professional review committees to reflect new, non-hospital-based models of care.
- Procedural improvements, including:
- Expand the jurisdiction of the Committee on Anticompetitive Conduct to include any claim of unreasonable conduct related to peer review.
- Require training for service on professional review committees.
- Require all professional review organizations to have, and uniformly apply, written triggers for review and investigation.
- Require that physicians under review have reasonable notice and an opportunity to respond to issues being considered, as well as access to such information and documents as are reasonably necessary to respond to a review or investigation.
- Require all professional review organizations to institute a process for objectively validating the efficacy of its professional review system, e.g., external audits.
- Stipulate that CPRA confidentiality protections may not be undermined by technical defects in a review, provided the process itself complies with CPRA and an individual review is in substantial compliance with the process.
- Allow credentialing entities to share peer review data without losing confidentiality protections (this recommendation echoes a bill that CMS and COPIC tried to pass some years ago).
(BOD-1, AM 2011; Reaffirmed, BOD-1, AM 2014)
285.994 Quality of Care and Medical Staff Review
The Colorado Medical Society (CMS) believes that all quality of care issues pertaining to inpatient care should be referred to and evaluated by the hospital medical staff to determine whether physician and/or hospital quality assurance problems exist. The CMS maintains that medical staffs must be involved in resolving all hospital quality assurance problems pertaining to patient care and should be encouraged to take the initiative in these matters. The CMS supports the following principles regarding medical staff and quality assurance:
- The care of the hospitalized patient should be under the direction of a physician (M.D. or D.O.) who is a member of the medical staff;
- Peer review of medical care should be conducted by physicians on the medical staff;
- Utilization review and Quality Assurance activities should be conducted under the direction of the medical staff;
- Nursing and allied health staff should participate in quality assurance activities when appropriate; and
- Quality assurance activities should not be conducted without medical staff involvement.
(Motion of the Board, March 2004; Reaffirmed, BOD-1, AM 2014)
285.995 Support of Physician Peer Review
The Colorado Medical Society (CMS) supports the concept of physician peer review and the direct involvement and participation of Colorado physicians in the peer review process.
(Motion of the Board, March 2004; Revised, BOD-1, AM 2014)
285.996 Health Plan External Grievance Review
All external grievance review procedures for adverse health plan decisions shall include the following basic components:
- It should apply to all health carriers in Colorado;
- Grievances involving adverse determinations can be submitted by the policy holder, their representative or their attending physician;
- Issues eligible for external grievance review should include, at a minimum, denials for a) medical necessity determinations; and b) determinations by a carrier that such care was not covered because it was experimental or investigational;
- Internal grievance procedures should generally be exhausted before requesting external review;
- An expedited review mechanism should be created for urgent medical conditions;
- Independent reviewers in the same community should be used whenever possible;
- Patient cost-sharing requirements should not preclude the ability of a policyholder to access such external review;
- The overall results of external review should be available for public scrutiny with procedures established to safeguard the confidentiality of individual medical information; and
- External grievance reviewers shall, whenever possible, obtain input from physicians involved in the area of practice being reviewed. If the review involves specialty or sub-specialty practice, the input shall, whenever possible, be obtained from specialists or sub-specialists in that area of medicine.
(RES-26, AM 1998; Reaffirmed, BOD-1, AM 2014)
285.997 Peer Review, Corrective Action and Exclusive Contracts
Exclusive contracts should never be used as a mechanism to solve quality assurance problems in lieu of appropriate peer review processes. When there are quality assurance issues, exclusive contracting may result but the medical staff should be involved through the application of appropriate peer review processes, bearing in mind due process procedures.
(RES-37, AM 1991; Reaffirmed, BOD-1, AM 2014)
285.998 Center for Personalized Education for Physicians (CPEP)
The Colorado Medical Society supports the Center for Personalized Education for Physicians.
(RES-1, AM 1991; Reaffirmed, BOD-1, AM 2014)