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The nation’s largest health insurer, Aetna U.S. Healthcare, has eliminated its "all products" clause, which required physicians to enroll in every Aetna program in order to contract with the health plan. In making the announcement in December, John W. Rowe, MD, Aetna’s president and chief executive officer, also said that the insurer was working on other physician policy changes on a market-by-market basis to reflect the specific local needs. Rowe’s news was followed by announcements in several states of specific changes that Aetna has made to improve relationship with doctors in those states.
D. Ted Lewers, MD, chairman of the American Medical Association’s board of trustees, called Aetna’s elimination of the all-products clause "a good first step toward restoring confidence in Aetna’s ability to foster collaborative and cooperative relationships with physicians that benefit patients." The AMA has been speaking out against that provision of physician contracts for more than two years, he adds, and Aetna eliminated its all-products clause effective Jan. 1.
The new policy applies to all non-hospital-based physicians. In the case of existing contracts, the physicians will have the opportunity to opt out of a product line by giving Aetna 90 days notice when the contract comes up for renewal. "One of my highest priorities is improving physician relationships with the goal of improve health care quality. Many of our physicians have told us that our all-products policy has been a concern. Creating a more flexible contracting policy is just one example of changes we are making to reduce the hassle factor,’" Rowe says.
The company is working on other physician policy changes on a market-by-market basis to reflect local needs that should be addressed, he adds.
In California, Aetna and the California Medical Association announced an agreement on how the provider would give California physicians more flexibility. The agreement came "after 10 years of strife between doctors and Aetna" according to CMA Chief Executive Officer Jack Lewin, MD. "The AMA is encouraged that the California Medical Association and Aetna have agreed to initiate ever more far-reaching improvements in Aetna’s business practices in California," Lewers says.
Under the agreement with the CMA, Aetna agreed to:
• Eliminate the all-products clause.
• Pay actuarially sound capitation rates and begin paying them from the time the patient joins the health plan, rather than waiting for the patient to choose a primary care provider. New patients who do not pick a physician will be assigned to a primary care physician near their home with the option of changing doctors at a later date.
• Pay the cost and administration of vaccines recommended for children.
• Pay for new technology when Aetna and the CMA agree that it is the recognized and appropriate standard of care.
• Stop forcing doctors to take on insurance risks for the cost of the patient’s prescriptions.
The organizations also agreed to create a liaison team with representatives from Aetna and the CMA to identify and resolve issues that occur in the future. "Too often in the past, our relationship with health plans has been characterized by rancor and we have tried to resolve disputes through the courts and the legislature. We hope the future will be built on cooperation, recognizing a mutual desire to serve the needs of patients," Lewin says.
Meanwhile, Aetna’s Southeast Region Medical Director, Catherine Palmier, MD, outlined new programs and options for members and physicians in Florida.
• simplifying the pre-certification process for HMO-based products, including outpatient surgery, most durable medical equipment, and many types of injectable drugs;
• eliminating the need for referrals for laboratory services;
• allowing patients to use specialists as their principal physicians with certain appropriate medical conditions;
• agreeing to fee-for-service payments for independently contracted primary care physicians with 100 or fewer Aetna U.S. Healthcare HMO members;
• agreeing to give providers 90 days notice of significant payment or administrative changes to contracts.
In New Jersey, AETNA has agreed to:
• Expand external review to cover pharmacy claims, standing referrals, and emergency care as well as medical necessity and experimental treatment coverage decisions.
• Eliminate pre-certification or referral for magnetic resonance imaging/magnetic resonance angiogram services for members of HMO-based plans.
• Allowing direct access to specialists for members of some HMO products.
• Reduce the number of formulary drugs requiring pre-certification and step-therapy to 33 from 92.
Aetna is the nation’s leading provider of health insurance with more than 19 million health care members, 14 million dental members, and 11 million group insurance customers.