Section 3.12 - Qualified Patient Care Assessment Program - Health Maintenance OrganizationsNotwithstanding 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; andiii. 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.