Tensions grow between Texas physicians and MCO

After years of escalating tension, two large Dallas-area physician practice organizations have canceled their HMO contracts with mega-insurer Aetna US Healthcare.

In retaliation, Aetna invoked its "all products policy," requiring physicians to participate in all of Aetna’s products in order to participate in any of them. Additionally, Aetna has brought anti trust charges against the largest of the two physician organizations, the 560-physician Genesis Physicians Practice Association.

In a countermove, the Dallas County Medical Society, the Texas Medical Association, and the American Medical Association (AMA) have filed comments with the Justice Department opposing Aetna’s proposed purchase of Prudential HealthCare, which would make it the nation’s largest health care insurer.

"This is the first time the AMA has publicly opposed a health insurance consolidation," says Randolph Smoak, MD, chairman of the AMA’s Board of Trustees. However, the AMA was forced to act because of a number of issues, such as the market share the new consolidated Aetna would have and the history of difficulties physicians have had with Aetna US Healthcare, says Smoak. "These problems are particularly acute not only in Texas, but six to eight other states, as well, " he says.

"While this may be the first time the AMA has opposed a health insurance consolidation, it almost certainly will not be the last," says Todd Vande Hey, the AMA’s vice president for private-sector advocacy. "The AMA will challenge anticompetitive consolidation in health care and help physicians to collectively bargain with consolidated insurance and hospital entities."

Medicare will cover EECP coronary therapy

Vasomedical Inc. of Westbury, NY, says the Health Care Financing Administration has extended Medicare coverage to enhanced external counterpulsation (EECP), Vasomedical’s noninvasive outpatient treatment for coronary artery disease. Medicare coverage of the EECP procedure includes patients with disabling angina who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical interventions such as percutaneous transluminal coronary angioplasty or cardiac bypass.

EECP is a noninvasive, atraumatic procedure involving a series of compressive air cuffs placed on the lower extremities, with inflation and deflation modulated by events in the cardiac cycle via microprocessor-interpreted electrocardiogram signals. The beneficial effects of the procedure on perfusion of the ischemic myocardium in patients with coronary artery disease are sustained between treatments, and may persist long after completion of a course of therapy, say company officials.

Heart laser procedure recommended for coverage

A Health Care Financing Administration advisory group has recommended that Medicare approve payment for transmyocardial revascularization (TMR) procedures performed with Food and Drug Administration-approved devices.

The recommendation was made by staff in HCFA’s Coverage and Analysis Group following its review of scientific evidence on the medical effectiveness of TMR. The coverage staff recommended the rescision of the current Medicare national noncoverage instruction and the adoption of a new coverage policy to allow payment for TMR consistent with FDA-approved uses of the devices to perform TMR.

The memorandum recommends coverage of TMR "as a late or last resort for patients with severe . . . angina . . . which has been found refractory to standard medical therapy, including drug therapy at the maximum tolerated or maximum safe dosages. In addition, the angina symptoms must be caused by areas of the heart not amenable to surgical therapies such as PTCA, stenting, coronary atherectomy or coronary bypass."

The HCFA staff recommendation is being forwarded internally for final agency approval and the issuance of a formal instruction requiring coverage for TMR.