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The American Medical Association (AMA) and the Florida Medical Association (FMA) are calling Aetna/U.S. Healthcare physician contracts unfair to both physicians and patients .
The nation’s second largest managed care company, which is based in Blue Bell, Pa., should not have the right to change patient care procedures and policies unilaterally, according to the AMA.
The AMA issued a letter October 31 to the company outlining numerous concerns following a legal review of the insurer’s contract with Florida physicians.
The FMA asked the AMA to review the Aetna/U.S. Healthcare contract after the company refused to discuss the contract with the state medical association, according to a press statement AMA released last month explaining its concerns.
The AMA has received similar complaints about the managed care company’s contracts from physicians in five other states.
"We believe the contracts clearly are not in the patient’s best interest," said D. Ted Lewers, M.D., a member of the AMA Board of Trustees, in the press statement. "These provisions blur the line between services that are medically necessary and services that the plan simply does not want to cover."
Moreover, the contract allows the managed care company to override a physician’s decision about medically necessary care without providing an appeals process.
There are also gag clauses, which may violate Florida state law, according to the AMA press statement.
"The inclusion of an apparent gag clause in the Florida contract is particularly surprising given U.S. Healthcare’s public assurances in February 1996, prior to its merger with Aetna, that it was eliminating all gag clauses from its contracts. In 1997 Florida became one of 35 states to pass laws banning the use of gag clauses in managed care contracts," according to the press statement.
The managed care contract also compromises patient privacy by requiring physicians to disclose confidential medical records without a patient’s consent.
Lewers commented, "There is a trend in which managed care companies with large market shares offer one-sided contracts on a take-it-or-leave-it basis. Yet physicians who sign these contracts are virtually signing away their ability to properly advise their patients and provide the care they believe is clinically indicated - the very service they entered into the contract to provide," he said in the press statement.
Aetna/U.S. Healthcare has not responded directly to the AMA about its contractual concerns, according to an AMA spokesperson at press time.
Nonetheless, the managed care company issued a response to the AMA’s concerns in its own press statement: "While we routinely negotiate provider contracts with individual providers, antitrust and other concerns prevent us from negotiating contract terms with the AMA."
The AMA denied that it was attempting to negotiate any physician contract, but was rather expressing its concerns.
"As with other comments we receive, we will consider the AMA’s comment letter and are reviewing [the AMA’s] proposed model contract," according to Aetna/U.S. Healthcare.
The AMA’s Model Medical Services Agreement is an initiative of the AMA’s Division of Representation, and a copy can be obtained by calling (312) 464-5490.
The managed care company disagreed with AMA’s contention that a certain contractual provision restricted physician-patient communication. But, "to avoid any possible confusion, we deleted the provision prohibiting doctors from providing or threatening to provide inferior care or implying to [patients] that their care or access to care will be inferior due to the source of payment."
Aetna/U.S. Healthcare also denied that its contracts are coercive. "No one is forced to sign, and negotiation of specific terms is routine." Moreover, "termination without cause is a two-way street; generally both parties can end the relationship with 90 days’ notice," according to the statement.
The managed care company maintains that medical decisions are the physicians’ responsibility and they are not liable for the company’s decisions. "We make coverage determinations as required by customer contracts and applicable law."
Appeals processes as required by federal and state law "are in place in all Aetna/U.S. Healthcare HMO’s, including special provisions for prompt resolution when care is urgently needed."
The company also maintains that it has the right to review "member medical records, which is absolutely essential to quality assessment, credentialing, developing HEDIS [Health Plan Employer Data and Information Set] data, achieving NCQA [National Committee for Quality Assurance] accreditation, regulatory compliance, and disease management."
Regarding unilateral changes affecting the relationship between the provider and the plan, Aetna/U.S. Healthcare responded that "policies need to be changed frequently to reflect new regulations and legislation, governmental directives, quality initiatives, new products, competitive factors, and cost containment."
"It would be impractical to amend hundreds of thousands of provider contracts in order to reflect new policies."