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Doctor Supply, HMO Liability, Prescription Drugs, Medicare, Managed Care
|Jump to:||Choose article section... Doctor Supply: An exodus from California? Prescription Drugs: Manufacturers dangle more lures Medicare: A federal court lifts the veil of secrecy from PRO investigations Managed Care: Chiropractors try to adjust the way HMOs do business HMO Liability: While Congress talks, another state acts|
More than 40 percent of physicians surveyed by the California Medical Association say they'll leave patient care in the state within three years, and another 12 percent plan to reduce the time spent in patient care. The doctors' dissatisfaction generally stems from low reimbursement, managed care hassles, and government regulation.
Two out of three respondents say they'd still have chosen medicine as a career, even if they had anticipated its problems. But few want their children to follow them.
Meetings and events for physicians are increasingly viewed as an integral part of pharmaceutical promotion, according to an audit by Scott-Levin, a consulting and market research firm. And that marketing strategy apparently pays off: Last year, drug companies sponsored an estimated 314,022 events11 percent more than in 1995. At least half the doctors in attendance said they would begin or increase prescribing a promoted product.
Allergists/immunologists, otolaryngologists, and endocrinologistsspecialists who generally receive fewer invitationsjumped at the chance to attend. Primary care physicians and cardiologists were most likely to decline.
A federal district court has ruled that when a Medicare peer review organization investigates a patient's complaint about quality of care, the PRO must disclose its findings to the complainant, even if the doctor objects. It's clear, the court said, that "Congress specifically . . . rejected language that would have required a PRO merely to inform a complainant that his complaint had been received and addressed." The Department of Health and Human Services "cannot by its interpretation, override the congressional will."
The California Chiropractic Association is suing American Specialty Health Plan, the nation's first and largest managed care plan specifically for complementary medicine. The lawsuit claims the plan's business practices are putting many chiropractic practices at risk of going under.
CCA contends that the health plan has enrolled over 90 percent of managed care patients with chiropractic coverage in the state, but contracts with just 20 percent of the states' chiropractors. Moreover, the CCA says, the plan's market share leaves no room for contract negotiations.
The suit charges that ASHP routinely denies, without explanation, treatment requested by doctors on its panel, refuses to return or account for more than $8 million in withholds, "loses" claims, terminates providers without cause, and has cut reimbursement levels below the cost of providing care. The CCA likens the situation to that of physicians in 1999 when the California Medical Association Foundation released a report warning that managed care was pushing many medical practices to the brink of bankruptcy.
But ASHP President/CEO George DeVries says the suit is "without merit," and the company plans to "vigorously defend it." Although the health plan doesn't contract directly with the CCA, DeVries notes, the HMO's provider panel is currently open to anyone who meets its credentialing criteria. ASHP, as a supplemental insurer, provides coverage to beneficiaries of 10 health plans, and contracts directly with 11,000 employers. Some 4 million of California's 35 million residents are covered by the plan.
New Jersey has become the latest state to pass legislation that would allow patients to sue HMOs. Pledging to sign the measure, Acting Gov. Donald T. DiFrancesco said: "Health decisions should be made in the doctor's office, not in the boardroom, [and] doctors shouldn't be forced to practice medicine with hesitancy for fear of having needed tests or treatments denied to their patients."
Texas enacted the first right-to-sue law in 1997. Since then, similar laws have passed in Georgia, California, Washington, Arizona, Maine, Oklahoma, and Oregon. In addition, Missouri, New Mexico, and Louisiana passed laws that utilize more-limited approaches to health plan liability, according to the National Conference of State Legislatures.
Joan Rose. Practice Beat. Medical Economics 2001;17:20.