Feature Article

CMA’s Physician Advocacy Programs

By Nileen Verbeten, MBA, MSW

ad•vo•ca•cy: active support, as of a cause

Physician advocacy at the California Medical Association takes many different forms. One form is legal advocacy, such as our ongoing RICO lawsuit against abusive payor practices, our fight to protect medical staff rights, and our successful prevention of Medi-Cal cuts. We also research cases and issue briefs whenever the Medical Board of California fails to follow appropriate due-process procedures in evaluating complaints against physicians.

Another form of advocacy is our active engagement with the state legislature, particularly as we head into the current session with full expectation of a MICRA battle on our hands. Protecting MICRA will be an enormous undertaking. Not only will our staff need a detailed understanding of how MICRA works, they must also be skillful in translating this understanding into persuasive arguments that can influence legislators against an onslaught of opponents who would gain financially from MICRA’s repeal. This advocacy effort will further require physicians in Sonoma and other counties to contact their local legislators and reinforce critical messages when a decision point nears.

A third form of advocacy is to make sure physician interests are addressed when state regulations are written. In 2004, for example, we worked closely with the Medical Board to monitor MBC activity, encourage MBC’s compliance with its own rules, and focus on quality of care in regulations intended to protect the public. In the pay-for-performance arena, CMA regularly meets with the Pacific Business Group on Health and other entities to voice our opposition to incentive measures that are not valid proofs of quality. We also oppose incentives that essentially transfer compensation between providers.

These three forms of advocacy—legal, legislative, and regulatory—focus on external factors affecting all California physicians. To these three, CMA has recently added a fourth: the Practice Empowerment Program. This advocacy program, which grew out of our 2003 study on the needs of solo and small-group practices, is specifically targeted to CMA members.

The study found that solo and small-group practices are in significant pain and increasing risk as they try to cope with low reimbursement, high overhead, and overwhelming administrative burdens. Key challenges are claims-submission processes, payor delays and denials, inefficient procedures, excessive rework, staff turnover and training, and an absence of technical resources and information infrastructure.

We have tried to address these concerns by developing useful resources. The following examples are available free to CMA members in the members-only section of the CMA website at www.cmanet.org. (After logging into the members-only section, select Physician Advocacy, then Reimbursement Advocacy.)

• Getting Paid: Strategies to Maximize Reimbursement—A Focus on Revenue and Collection. This primer focuses on the billing and collection process, the proper procedures that should be followed, and the steps to take if you still don’t get paid.
  
  
• Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting. This detailed guide helps you evaluate your payor relationships, identify where improvements are needed, and prepare to make those improvements. It includes sample letters and worksheets to help you and your staff get ready for payor negotiations.
  
  
• Unfair Payment Practices: Tools to Stop Payor Abuse Now. This online training session, based on CMA’s seminars on abusive payment practices, educates office staff on the protections afforded by AB 1455.
  
  
• Payor Profiles. Descriptions of the major payors, including financial performance, product lines, and geographic coverage, as well as helpful contacts and links.

An additional resource is the Reimbursement HelpLine at 888-401-5911, which CMA members who are having problems with payors can call for assistance. Our experienced staff can help through educating, coaching, and occasionally directly intervening.

CMA sponsored a Solo Summit at our 2004 Leadership Academy. This meeting showcased physicians who have successfully abandoned the strictures of third-party reimbursement. It emphasized key areas of health information technology that affect solo and small-group practices both now and in the future.

We are also negotiating with vendors who specialize in solo and small-group practices. Athenahealth, for example, has developed a system that streamlines work to get physicians paid faster, with fewer denials, hassles, and rework. The system will be officially rolled out this spring, but Primary Care Associates in Sonoma County has already implemented it, with good financial results.

Another CMA-approved vendor, ePocrates, offers a drug reference guide in a handheld personal digital assistant (PDA). Similar in content to the Physician’s Desk Reference, the guide can be updated weekly by synching the PDA to the ePocrates website. The guide also includes dosing calculators, retail cost information, payor formularies, and drug interaction warnings. By providing current information in a highly accessible format, it helps reduce guesswork and rework. The guide will be rolled out this spring.

A third resource is a relationship with KLAS Enterprises. KLAS collects and reports customer experience with health information technology products. Through this relationship, we can provide low-cost or free access to the experience of others with specific technology products.

Finally, we have just submitted a grant proposal to the Physicians Foundation to fund a project titled “An Extreme Makeover of the Solo and Small-Group Practice.” If approved, this project will allow us to work with selected practices to redesign and, wherever possible, automate office workflows to eliminate redundant and non-value-added steps. The goal is to demonstrate improved revenue, reduced costs, and decreased hassles, and to provide templates and tools for other practices to obtain the same results.

CMA advocacy is all around you: in the courts, the legislature, the rule books, and now in your own practice. Our advocacy even extends to the future of health care. Be a part of it.

Ms. Verbeten is vice president of the Center for Economic Services at the California Medical Association.

Sonoma Medicine, Volume 56, Number 2 (Spring 2005).