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Reimbursement, Quality Care, Medical Records, Tomorrow's Doctors, Medical Residents, Quoteworthy, Medicare, Looking Ahead
A state superior court has rejected the California Medical Association's attempt to make health plans responsible for reimbursing physicians when IPAs, physician practice management groups, and other intermediaries fail to do so. (See "The California nightmare: Is this where managed care is taking us?" Jan. 24, 2000.)
The CMA contends that the plans' refusal to pay violates the state's Health & Safety Code. But the court refused to hear the case, citing an earlier ruling by the California Department of Corporations that sided with the health plans. The DOC had determined that the code doesn't obligate insurance plans to pay for services; it merely requires that, when they pay, they do so within a specified number of days. The medical association, which believes the DOC's ruling to be seriously flawed, is weighing an appeal.
Meanwhile, the CMA has filed an amended suit in superior court alleging that the health plans have been unjustly enriched because they've collected premiums but haven't paid providers. Physicians and hospitals are still waiting for payment for some $100 million in care rendered to health plan enrollees. As a result, many physician groups have gone bankrupt or are in serious financial trouble, the CMA points out.
Defendants in the suit are Aetna US Healthcare of California, Blue Cross of California, Blue Shield of Califor nia, Health Net, Maxicare Health Plans, PacifiCare of California, Prudential HealthCare of California (now a part of Aetna), and United HealthCare of California.
Physicians view themselves as "outcome managers" and define quality care as the best possible outcome, according to a study by the Rhode Island Department of Health. But patients, when asked how they perceive quality care, are more likely to cite the process than the success of the treatment.
And patients often differentiate between hands-on care and other services that a hospital provides. For example, more than half of the 454 Rhode Islanders surveyed see hospital services as ancillary and supplementary to the diagnostic and treatment services provided by their own doctors.
When asked to define what "quality in a hospital" means, only 31 percent of respondents cited treatment success. More than double that, 63 percent, mentioned personal carethat is, how well they were treated, the staff's communication ability and attentiveness to their personal needs, and whether they felt respected.
Yet, when asked what information should be included in a report on hospital quality, the respondents were more interested in effective treatment than personal comfort. They cited:
A Florida appellate court has sided with a physician who refused to hand over thousands of records to Humana after he'd been terminated as a participating physician in its HMO. The doctor challenged a clause in his contract that described the records as "the property of Humana" and required that they be handed over "immediately upon demand."
The physician did return those records for which Humana could produce a patient authorization. But he withheld the rest because, he said, they belonged to the patients. Humana sued, and the doctor countersued.
The doctor argued, successfully, that Humana didn't qualify as the "owner" of the records. The law prohibits disclosure of medical records to anyone but the patient, his doctor, or his legal representative. The HMO thus had no authority to obtain them without patients' written consent.
Although Humana is complying with the ruling, it still contends that delaying transfer of the records interferes with continuity of care. Possible changes in the contract language are being considered, but such revisions won't affect contracts elsewhere in the country, Humana says.
Last year, the number of women entering medical school increased nearly 4 percent to 7,412, the Association of American Medical Colleges reports. Females now make up the majority of first-year students in almost one out of three US medical schoolsand 46 percent of entering students nationwide. In 1990, by comparison, females equaled or outnumbered their male counterparts in just 10 of the nation's 125 medical schools.
But even as the number of women accepted to medical school is growing, the overall number of doctor-wannabes is shrinking. The applicant pool38,534 in 1999was 6 percent smaller than in '98 and marked the third consecutive decline from 1996's all-time high of nearly 47,000.
In New York City, medical residents play a major role in providing care for low-income people who rely on Medicaid.
According to the United Hospital Fund's New York University Ambulatory Care Provider Survey, physicians-in-training are the most common primary care providers at the facilities surveyed, accounting for more than half the staff. Moreover, the findings suggest that heavy reliance on medical residents results in fewer attendings at those facilities. Among sites that don't use residents, for example, 79 percent of providers are attendings. At sites that employ residentsincluding outpatient departments, freestanding health centers, and satellite clinicsthe proportion of attendings drops to just 35 percent. While residents account for 42 percent of the city's facility-based primary care workforce overall, they staff nearly half of the city's outpatient departments.
Unlike patients in commercial managed care plans, whose overall satisfaction has been steadily declining, Medicare HMO enrollees are satisfied with their Medicare+Choice plans, according to a Caredata.com survey. Even the well-publicized plan pullouts don't appear to have made beneficiaries wary of managed care plans. Last year, for instance, 68.5 percent of respondents said they were highly satisfied, up from 66.9 percent in 1998. And 80.8 percent of beneficiaries polled in 1999 said they were likely to re-enroll, compared with the 78.6 percent who considered reupping a year earlier.
Currently in its third year, the Caredata.com Managed Medicare Member Survey is said to be the largest independent effort to evaluate and report the satisfaction of Americans in Medicare HMOs. Nearly 15,400 Medicare+Choice members participated in the survey, which was conducted from June through early October 1999. The researchers evaluated 40 plans in 19 markets.
"Like Toto in The Wizard of Oz, we've pulled back the curtain to reveal that, when it comes to these suits against the managed care industry, the all-powerful trial lawyers are relying on smoke and mirrors. Plaintiffs' lawyers are trying to pressure the industry to settle quickly because they don't have a legal leg to stand on."
Glenn Lammi, president of the Washington Legal Foundation, attacking the legitimacy of recent class-action (RICO) suits against HMOs
A handy reference of telephone numbers, as well as e-mail and Web site addresses for some sponsoring organizations.
Cancer Control Month
American Cancer Society
1599 Clifton Road NE
Atlanta, GA 30329-4251
Web site: www.cancer.org
Contact: local chapters
IBS (Irritable Bowel Syndrome) Awareness Month
International Foundation for Gastrointestinal Diseases
PO Box 170864
Milwaukee, WI 53217
Web site: www.iffgd.org
Contact: Nancy Norton
National Autism Awareness Month
Autism Society of America
7910 Woodmont Ave., Suite 300
Bethesda, MD 20814-3015
Web site: www.autismsociety.org/asa_home.html
National Child Abuse Prevention Month
Prevent Child Abuse America
200 South Michigan Ave., Suite 1700
Chicago, IL 60604
Web site: www.preventchildabuse.org
National STD Awareness Month
American Social Health Association
PO Box 13827
Research Triangle Park, NC 27709
Web site: www.ashastd.org
16-22 National Infants Immunization Week
Centers for Disease Control and Prevention
National Immunization Program
1600 Clifton Road, Mail Stop E05
Atlanta, GA 30333
Phone: 800-232-2522 (English) or 800-232-0233 (Spanish)
Web site: www.cdc.gov/nip
Contact: Curtis Allen
16-22 National Organ and Tissue Donor Awareness Week
National Kidney Foundation
30 East 33rd St.
New York, NY 10016
Web site: www.kidney.org
Contact: Local chapter
Joan Rose. Practice Beat.