June 2000 • Volume 6 • Number 6
Aetna, physician groups weigh in on settlement terms
BY SHERI PORTER
It's a done deal in Texas, but a recent settlement between the Texas attorney general and Aetna U.S. Healthcare has raised some eyebrows.
On April 11, Texas Attorney General John Cornyn announced a voluntary agreement with Aetna (http://www.oag.state.tx.us/notice/avc_fin1.pdf) that put to rest a 1998 lawsuit accusing the company of offering doctors financial incentives to limit patient care. Initially, the settlement was touted as a model for managed care reform across the country. But as physician groups and lawyers wade through the 50-page document, comments such as "ambiguous" and "full of loopholes" keep popping up.
For example, the May 8 issue of The National Law Journal points out that under the agreement, licensed medical professionals determine medically necessary care. But patients may be surprised to learn the provision includes Aetna physicians and medical directors in addition to their own doctors.
The article also objects to a provision that deals with the relaxation of Aetna's "all-products" requirement forcing physicians to participate in all of Aetna's health plans even if they want to participate in just one. This is good news for physicians in small practices, but large groups don't have that option.
Kim Ross, chief lobbyist for the Texas Medical Association, said his group has brought its concerns directly to the attorney general's office and to the leadership of Aetna via meetings and conference calls.
"There has been some progress in closing the gap between the language as we read it and the intent of the agreement," Ross said. "We think we can stand down after just a little bit more work with our attorney general."
John Kelly, M.D., Aetna's director of physician relations, said physicians should welcome the agreement because it offers financial protection and helps physicians and patients understand how the company conducts business.
"We chose to sit down with the attorney general to arrive at an agreement that goes way beyond the issues raised in the original complaint," Kelly said.
Some physicians, such as AAFP Director James Martin, M.D., of San Antonio, remain upbeat. Martin sees the settlement as a great start. "It will help me retain continuity of care with my patients, it gives my patients more information in making health care decisions, and the agreement provides avenues to redress perceived wrongs," he said.
Kelly pointed out that Aetna will create an office of ombudsman to assist HMO members in dealing with appeals and complaints. He said the agreement ushers in a new era in managed care.
"We think many of the principles that are embodied in the Texas agreement provide a foundation for some of the adjustments that we're considering for our business practices elsewhere in the country," Kelly said.
But critics argue that the Texas deal can't be used as a national template because the settlement relies heavily on existing Texas law to plug loopholes. In addition, many of the provisions duplicate existing Texas law, leaving some people to wonder why Aetna was not assessed penalties.
Tom Banning, director of legislative affairs of the Texas AFP, said, "To let Aetna off the hook without even collecting investigative costs the state spent on this case amounts to a slap on the wrist. This settlement sends the wrong message to other companies who are violating Texas law."
The AAFP has not officially commented on the Aetna settlement. But Banning said, "This agreement may turn out to be a better deal for managed care than for physicians and patients."
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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