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Obstacles hurting states' efforts to revamp physician credentialing

From the January 2000 ACP-ASIM Observer, copyright 1999 by the American College of Physicians-American Society of Internal Medicine.

By Bryan Walpert

Seven years ago, Bob G. Lanier, ACP-ASIM Member, had contracts with just six health plans. Today, the Atlanta rheumatologist has 35 plans, each requesting that he fill out recredentialing forms regularly.

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  Though the information he has to provide to the plans is similar, the forms are all slightly different and arrive throughout the year. Dr. Lanier, a solo physician, estimates that it costs more than $200 in his time to deal with each form.

  He is not alone. With health plans and hospitals across the country asking physicians to fill out credentialing forms every two years, physicians desperately need a solution that keeps them from having to submit the same information over and over, year after year.

So when a number of states began announcing plans to streamline the credentialing process, many physicians breathed a collective sigh of relief. Several states have standardized health plans' credentialing forms and created repositories in which physicians can put their credentialing data. The AMA has also launched an effort at the state level to build a repository of credentialing information that may one day be offered nationwide.

Now, however, as many of these efforts face serious obstacles, physicians' initial optimism is fading. In some states, health plans are still collecting their own information their own way. In other states, large credentials verification organizations (CVOs) are fighting legislation that threatens their profits. The result is that in many states, efforts to streamline credentialing efforts have been weakened. In some instances, the efforts to reinvent credentialing have become so convoluted that they are more difficult to navigate than the original credentialing processes they replaced.

Here's a look at some of those efforts and the successes and failures they've encountered.

Standardized forms, timing

At a basic level, physician groups in a number of states are working with health plans and hospitals to standardize the credentialing forms that physicians are asked to complete. State medical societies in Washington, Oregon and California have worked with health plans and hospitals to create standardized credentialing forms; similar work is underway in Vermont.

The idea is simple: Create a single form that physicians can complete once, often using computer software, and then send it out to anyone who requests it. While the forms vary somewhat from state to state, they typically include information on a physician's medical education, training, board certification and other information that health plans and hospitals want.

In other states, the idea of voluntary collaboration has been taken a step further. Maryland has not only created a standardized credentialing form, but it also requires health plans and other organizations to use the form. And Illinois legislators have created a standard form that health plans and hospitals must use. They have also standardized the credentialing cycle, so that once every two years physicians simultaneously send all their forms to health plans and hospitals.

More states are following suit: A bill in the Massachusetts legislature would create both a standard form and a uniform credentialing cycle. Oregon legislation that would have created a standard credentialing cycle did not pass this year, but analysts say that the Oregon Medical Association will probably try to introduce the legislation again.

Data repositories

The most ambitious state efforts, however, focus on centralizing the credentialing process, forcing hospitals and health plans to bypass physicians almost completely.

A good example is Florida, which last year created CoreStat, an electronic repository of credentialing data. As of Jan. 1 this year, hospitals and health care organizations looking for credentialing information on physicians must go to CoreStat, which is run by the department of health's division of medical quality assurance. Organizations are not supposed to ask physicians directly for any information, and they can only tap into the database if physicians have authorized the state to give information to those specific organizations. The state is still deciding whether it will charge organizations to access CoreStat data; a decision is expected later this year.

CoreStat, which was created with the support of the Florida Medical Association, tracks a wide range of physician information. This includes physician education, training and licensure; Drug Enforcement Agency certification; specialty board certification; Educational Commission for Foreign Medical Graduates certification; hospital affiliations; malpractice coverage; history of claims, suits, judgments or settlements; final disciplinary action; and Medicare or Medicaid sanctions.

While CoreStat will collect and disseminate the information, health plans and hospitals will be responsible for verifying it either themselves or by hiring a CVO. (The department will continue to verify information used to license physicians.)

Arkansas is following a similar strategy. A bill passed last year with the support of the Arkansas Medical Society calls for the medical board to become the sole CVO in the state once it is certified by the National Committee for Quality Accreditation (NCQA), which the state expects to occur by the end of this year. Once that happens, managed care organizations will be required to use the board as their source for data on physicians.

The Arkansas State Medical Board will collect much of the same data as Florida. Unlike Florida, however, Arkansas plans to verify the information.

Finally, Texas has passed a more narrow measure under which the board will collect and verify five pieces of data: identity, professional education, training, licensure and, if applicable, certification from the Education Commission for Foreign Medical Graduates. While it is unclear how the state will fund the initiative, which has the backing of the Texas Medical Association, it will require health plans and hospitals to go through the state board to get information on those five items.

AMAP

Another effort that is being launched at the state level is the AMA's American Medical Accreditation Program (AMAP). The program aims to create a single repository of physician data that health plans, hospitals and other organizations can access. The benefit to physicians is that they only have to fill out one form; the benefit to health plans is that physicians in the program have a stamp of quality approval similar to what the NCQA offers managed care organizations.

AMAP differs from most state efforts in two ways. While the program is being launched at the state level, the AMA hopes to eventually make AMAP a national service that contains information on all physicians, not just those from one state. In addition, AMAP plans to one day go beyond collecting standard credentialing information such as physician education and licensure. It also wants to test physicians for cognitive knowledge and to include performance measures that test physicians' skills.

For now, however, AMAP is focusing on collecting and verifying credentialing information from physicians. AMA members pay $50 to go through AMAP, while nonmembers pay $125. Health care organizations pay a fee of about $200 per physician for the credentialing information.

AMAP only markets in those states where it has an agreement with the state medical society. When AMAP enters a state, it contracts with a CVO, in some cases run by the state medical society, to verify the information.

Proponents say managed care organizations and hospitals—not just physicians—have a stake in one-stop credentialing. "Right now, every one of these entities is collecting information 20 times," said Larry Downs, director of public health and medical accreditation at the Medical Society of New Jersey. "The concept behind AMAP is to generate it once and share it."

Stumbling blocks

While these efforts may seem like an obvious way to streamline the physician credentialing process, they have encountered some serious stumbling blocks.

For one, since its introduction AMAP has faced a wide range of opposition. Ironically, the first serious opposition to AMAP came from within the AMA itself. Because many of the AMA's state affiliates were already involved in the credentialing business, they viewed AMAP as a threat and have been reluctant to get on board. The AMA has tried to allay those fears by pledging to include state affiliates in the AMAP process wherever possible.

The strategy has been only partially effective. AMAP's first state medical society, New Jersey, signed up in November 1997. As of last fall—nearly two years later—AMAP was marketing in only seven states and the District of Columbia. As a result, physician participation has suffered, and to date only 2,366 physicians have been reviewed for accreditation.

While the AMA was smoothing over relations with its state medical societies, it encountered more opposition over its decision to not include board certification as an element of physician accreditation. Nearly 20% of U.S. physicians are not board certified, and some within medicine have opposed automatically precluding those practitioners from going through the AMAP process. In addition, some specialty boards worried that if board certification was not included in the AMAP process, it might lose its value in health care.

After strong opposition from specialty societies, the AMA blinked. It resolved the issue by promising to make board certification a requirement for AMAP by the year 2005.

More opposition has come from an alliance of medical societies and specialty boards that includes the College. The Quadrispecialites Group includes ACP-ASIM and the American Board of Internal Medicine along with medical societies and specialty boards representing family medicine, pediatrics and ob/gyn. The Council of Medical Specialty Societies has also joined the fight, and the American Board of Medical Specialties is taking part as an observer.

The group has argued that the AMA cannot run a company that accredits members who pay it dues. Walter J. McDonald, FACP, the College's Executive Vice President, explained that while medical organizations like the College need to be involved in setting standards, they risk a conflict of interest by getting involved in the actual accreditation process. The Quadrispecialties Group has called on the AMA to convert AMAP to an independent body that is not controlled by any single constituency or interest. The group at one point threatened to create a more independent accreditation body if the AMA did not meet its demands.

At first, the AMA balked, claiming that AMAP's original business plan gave it enough independence to avoid any conflict of interest. Then in June of last year, AMAP's board appeared to bend a little when it voted to make the program "independent." Exactly what that means is not yet clear, and the Quadrispecialties Group is continuing to pressure the AMA to divest itself of AMAP.

Another major challenge facing AMAP is how to enlist health plans, hospitals and other organizations that would use its information to credential physicians. The program's success in serving as a central repository for credentialing depends on the participation of health care organizations that are willing to pay for the information. As of late last year, only two plans had signed up to buy credentialing information, one in New Jersey and one in Utah.

AMA officials are looking at other ways to get health plans involved. Independent practice associations (IPAs), for example, could pay for the process and use AMAP credentials data as a way to make themselves more attractive to health plans. About half a dozen IPAs have put their physicians through the process in New Jersey, Connecticut and Massachusetts, according to AMAP officials.

Problems in the states

While state efforts have the imprimatur of state medical societies and many legislators, many have not fared much better than AMAP. Analysts point out that many of these efforts are hard-won compromises that don't go as far as physicians would like, showing how hard it is to garner the necessary cooperation among physicians, health networks and CVOs to reduce the paperwork involved in credentialing.

 

Collaboration among hospitals, health plans and physicians even on something as seemingly simple as a standard form is "damn hard," as one medical society official put it. In Oregon, for example, parties worked for a year and a half to come up with a form. It then took another year and a half before every health plan formally endorsed it, and a handful of hospitals still have not done so.

Legislative solutions aren't always a panacea, either. Ohio passed legislation in late 1997 requiring HMOs to use a standard credentialing form. Not long after the form began circulating in May 1999, one health plan started using an addendum with about 40 questions, some asking for information similar to that on the standard form, said Tim Maglione, director of legislation at the Ohio State Medical Association. The plan agreed to stop using its addendum after the medical association protested, he said.

But perhaps the greatest threat to state efforts to streamline credentialing comes from CVOs, which stand to be put out of business by many of these state efforts. Because so many states have been looking at ways to streamline physician credentialing, commercial CVOs last year banded together to create a trade organization to protect themselves: The Healthcare Provider Credentials Verification Association.

So far, the CVO industry has targeted large states where they have the most business to lose. CVOs protested the original Florida legislation in 1998, which would let physicians designate a CVO as the source for credentialing data but would have made the state the default CVO for physicians who did not choose a private company. CVOs felt they were in competition with Florida, which wouldn't have charged physicians for the service, said Lucy Gee, chief of the bureau of operations within the division of medical quality assurance.

While the CoreStat program officially began this month, agreement on some final details remains elusive, in part because of opposition from CVOs. A major sticking point is whether the state will charge organizations to get information from the database, a development that CVOs have been watching anxiously. "CVOs have been able to get the information from the doctor for free," said John B. Witty, president of Med Advantage, a national CVO based in Orlando. "The question is whether we will now have to pay the state for that information."

CVOs also interceded in Texas to oppose initial legislation that would have made the Texas State Board of Medical Examiners the sole source of credentialing in the state, much as Arkansas has done. Under the original legislation, the state would have collected a wide range of physician information. Under the terms of the final bill, which was influenced by opposition from CVOs, the board will collect data in only five areas.

"A lot of the credentialing requirements go beyond these five items," said Carlos R. Hamilton Jr., FACP, internist and endocrinologist at the Medical Clinic of Houston, president of the Harris County Medical Society and former president of the Texas Academy of Internal Medicine. Dr. Hamilton conceded, however, that standardizing some credentialing information "is better than nothing."

The weakened final version of the Texas legislation doesn't please everyone. On a practical level, the bill is essentially on hold while it awaits funding. Even if it is eventually funded and implemented, however, it won't be nearly as comprehensive as similar legislation in Florida and Arkansas. As a result, physicians will likely have to provide additional information to hospitals and health plans, leaving a less-than-streamlined credentialing process.

Bryan Walpert is a freelance writer in Denver

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