While at the California Medical Association House of Delegates, members of the Solo and Small Group Practice Forum (SSGPF) invited me to attend a presentation by Howard Lang, MD, dealing with peer review and medical staff issues. The evening evolved into a self-confessional discussion about insurance contracting.

At the House of Delegates, the SSGPF represents physicians practicing alone or in a small group of four or fewer. The CMA has more than 8,000 members fitting that category. Other practice forums include the Medium Group Practice Forum (5 to 150 doctors), the Large Group Practice Forum (150 to 1,000) and the Very Large Group Practice Forum (1,000 plus).

After a short presentation about a messenger model developed in Los Angeles County, various members spoke about dropping contracts. The sharing of personal experiences with contract termination has become chic. The solo practitioner sitting beside me made the observation that he felt like an Alcoholics Anonymous meeting erupted. "My name is H-----, and I terminated my contracts!" In response, knowing sighs from attendees filled the room. Those still afflicted with insurance contracts listened in admiration.

I shared that our group had recently terminated its contract with a major insurer. Our confessions continued, but never did we reveal details nor advise others to join us. The contracted physicians wondered whether they should also dare to say no.

Now shift to the floor of the House of Delegates. We learned that legis-
lation had been passed to study the peer review process in California,
and that the Medical Board of Calif-ornia had contracted with Lumetra to perform the assessment. Further, we learned that medical staff offices across the state had received letters from Lumetra demanding confidential peer review information.

What? They want what?!? Calls from medical staff offices to chiefs of staff and medical staff attorneys ensued. What information could, should or would be released? Was this information about peer review protected by SB 1157? Most hospitals collect reams of data about peer review. Physicians participating in review of other physicians assumed SB 1157 protected them from discovery. Hospital administration feared that exposure of cases with severe criticism of patient management could lead to increased legal liability. Who pays for the collection, copying and mailing of confidential patient and peer review data? Faced with another unfunded mandate from the state, what would medical staffs do? Could they dare to say no?

The House of Delegates passed a resolution requiring that the CMA legal department immediately look into the legality of the Lumetra demands. What information and how much detail should be released? Who can access the information? What assurances and legal protection from discovery exists? In essence, physicians were asking the CMA to give them the legal background so they could dare to say no.

It's not that we physicians are a bunch of naysayers. We gladly say yes to proven innovations, evidence-based medicine and new surgical techniques. Yet over the past 20 years, demands by insurers, legislators, regulators and even specialty boards have increased physician angst--and in that environment we must dare to say no.

Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at editor@socalphys.com.