Practice Beat

Joan R. Rose

DOCKET WATCH

A court battle with the muscle of 600,000 doctors behind it

Doctors can pursue a class-action suit against the nation's largest for-profit managed care companies, federal district court judge Federico Moreno has ruled. The doctors contend that the eight defendants—Aetna, Anthem Blue Cross and Blue Shield, Cigna, Coventry Health Care, Humana, PacifiCare Health Systems, UnitedHealthcare, and WellPoint—violated the federal racketeering law by conspiring to reduce, delay, and deny payments to physicians. Originally filed in May 2000 by the California Medical Association and individual doctors, the case has since been consolidated with similar suits filed all over the country. Now the US Supreme Court has agreed to hear an appeal by UnitedHealthcare and PacifiCare that the racketeering claims should be arbitrated.

In the same case, Moreno denied class-action status to patients. While it may be true that, in the broad sense, insurers have denied patients as a whole "the benefits of their health insurance," Moreno said, the patient issues would be "unmanageable."

MANGED CARE

California enacts a Bill of Rights for doctors

Observing that "HMOs and insurance providers have had the upper hand over doctors" for far too long, California Gov. Gray Davis has signed legislation to level the playing field. The new law prohibits health plans from changing a term of a physician's contract unless the doctor agrees. The plans would also have to give doctors at least 45 business days' notice of any intended change.

The California Medical Association praised the governor and the bill's sponsors for recognizing issues critical to physicians and patients. Without this law, CMA President-elect Ronald Bangasser explains, HMOs can change, at will, the fees they pay doctors for certain procedures and office visits or endanger care by reassigning patients to doctors who already have too many to take care of.

QUALITY CARE

Uncle Sam considers rewarding doctors for better care

CMS is readying a Medicare demonstration project that will offer physicians financial incentives for improving care for the chronically ill. During the three-year pilot program, participating physician groups will be paid on a fee-for-service basis, but they may earn bonuses by providing more-efficient treatment resulting in improved patient outcomes. The bonuses would be awarded only if actual Medicare spending for beneficiaries assigned to the group is below a predetermined performance target. CMS expects to select up to six group practices for participation in the project, which launches next year.

ACCESS TO CARE

What constitutes being a "child"?

To ensure that unborn children have access to needed services, the Bush administration has promulgated a new rule allowing states to define a fetus as a child. Beginning next year, states will no longer need a waiver from HHS to expand their State Children's Health Insurance Program (SCHIP) to include pregnant women and their unborn children.

Abortion proponents have accused the administration of using a health care program to undermine a woman's right to choose. But HHS Secretary Tommy Thompson contends that it's not about abortion; it's "about our undeniable health needs throughout the life cycle." The change is appropriate, he explains, because "federal policy has previously allowed welfare and Medicaid coverage for not-yet-born children."

HEALTH COSTS

Prescribing may get even trickier

Large employers (with 5,000 or more workers) will pay an average of 15 to 21 percent more for employee health benefits next year, according to Jim Foreman of Towers Perrin, a benefits consulting firm. That's the highest yearly percentage increase since the company began doing health cost surveys in 1989.

Among the factors Foreman cites for driving rates higher: pharmaceutical costs that are rising three to four times as fast as inflation. Consequently, he notes, many employers are moving to more-restrictive formulary drug coverage, as well as to tiered copays.

The author is a Contributing Writer.

 

Joan Rose. Practice Beat. Medical Economics 2002;22:15.