IN THE SUPREME COURT!!!
Supreme Court Agrees To Hear Doctors' Class Action Suit Against HMOs
The Supreme Court yesterday agreed to consider whether 600,000 doctors can jointly sue HMOs for violating federal racketeering laws or if they must settle their disputes through arbitration, the AP/Philadelphia Inquirer reports (Holland, AP/Philadelphia Inquirer, 10/16). In late September, U.S. District Judge Federico Moreno approved a class action lawsuit brought by the doctors and consolidated in Miami alleging that insurers -- including Aetna, Anthem, Cigna, Coventry, Humana, PacifiCare, UnitedHealthcare and Wellpoint -- routinely shortchanged physicians to make a profit. Attorneys for several of the HMOs appealed Moreno's ruling (California Healthline, 10/9). In the Supreme Court case, PacifiCare Health Systems v. Book, PacifiCare and UnitedHealthcare contend that some doctors signed contracts agreeing to settle the dispute in arbitration. Many companies favor arbitration because it is usually "cheaper, faster and more predictable" than a trial, the AP/Inquirer reports (AP/Philadelphia Inquirer, 10/16). CBS' "Evening News" Tuesday included a report on the suit (Rather, "CBS Evening News," CBS, 10/15). The full segment is available in RealPlayer online.
George W. Bush is working for the HMOs... (predictable) (8/5/2001)
When we all thought that the patients in
were going to have their Bill of Rights, George
W. Bush, the corporate president, cut a deal with Charles Norwood (a republican) and made
an amendment to protect the HMOs from being sued by the patients. If this becomes law, the
health insurers will remain the only industry in America that is not liable for its wrong doings.
They will go on free to harm people by denying the care they need.
THE PATIENTS' BILL OF RIGHTS!!!!!!!!!
Finally the US Senate has passed a significant Patients' Bill of Rights! Yes... it will allow patients
to sue insurance companies, hmos and managed care when they are harmed by their denial of
care. So far the insurance industry is the only industry in America that is not liable when it does
harm to people. The only problem now is, as expected, President Bush is threatening to veto it.
Shame on him! Write your representative to support the Bill that was passed in the Senate!!!!!
The Caucus (6/7/2001)
The APA Caucus for Psychiatrists Working With Patients Covered By Managed Care is growing. We not
have 44 members and our list serv has 37 subscribers. The movement is growing.
Interesting Group... (6/7/2001)
The National Coalition of Mental Health Professionals and Consumers is promoting a conference in New York on
"Shaping the Future of Mental Health Care: Let your voice be heard". Keynote Speaker will be Rep. Richard
A. Gephardt. Friday June 22, 2001 at the Farkas Auditorium, NYU Medical Center, Tisch Hospital. This group
is doing a good job working for parity, proper and ethical treatment for the mentally ill. It is also against behavioral
managed care for profit.
Here they come... (7/21/2000)
A full page add in the major newspapers in the Country. A newly formed "Coalition for Affordable Quality Health Care" (www.caqh.org) is now in a repentant course, admitting that they may not have been fair do doctors and patients, and promising to make things easier for both. Can you imagine how much they paid?... The problem is that by now, no doctor or patient believes on these people's good intentions. Who belongs to the coalition? Twenty four health insurers, including Aetna and Cigna. Interesting too that this happens when the Congress is trying to pass two important laws: the Campbell Bill that will allow doctors to negotiate with the health insurers as a group, and the Bill of Patients' Rights that will allow patients to sue their health insurance if they don't have proper treatment. Smart people no?
CLAIM THAT HMO'S SAVE MONEY IS LITTLE MORE
HEALTH AFFAIRS STUDY FINDS (7/17/2000)
Lull in health inflation in mid-1990's explained by other factors
While millions of Americans have been shunted into
HMO's over the past decade, there's no scientific evidence that managed care
saves money, according to a study in today's Health Affairs, the nation's
largest health policy journal.
"HMO premiums are up nearly
20% in the past two years, but a lull in
health inflation in the mid-1990's is so often attributed to HMO's as to have
become 'folklore,'" noted study author Kip Sullivan, who reviewed three
decades of research for the study.
"The claim that HMO's are
'efficient' than the fee-for-service (FFS)
plans they replaced is typically based on one of two research errors," said
Sullivan. "Either the study didn't take into account higher HMO
administrative costs, and only looked at cuts in hospital or doctor care, or
it didn't take into account factors like cherry picking healthier patients or
cost shifting to other payers as an explanation for lower premiums."
The study also notes that
other than the spread of HMO's explain
the mid-1990's lull in health inflation. These include the threat of
price controls and health reform in 1993, the well documented insurance
underwriting cycle (three years of high premiums followed by three years of
low premiums), a low inflation rate in the rest of the economy, and HMO's
lowering premiums (short-term) to gain market share.
"As managed care enrollment
has soared so have administrative expenses,"
said Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard.
"The percentage of workers in the health system dealing with paperwork has
increased from 18% to nearly 30%, belying the myth of HMO efficiency."
"The verdict is in on
control of health care. It has failed,"
said Dr. Quentin Young, National Coordinator of Physicians for a National
Health Program. "The US spends more on health care than any other country in
the world yet leaves 45 million uninsured and ranks 37th in performance
according to a recent study by the World Health Organization. It's time for
not-for-profit (single payer) national health insurance."
Copies of "On the 'Efficiency' of Managed Care
Plans," Kip Sullivan, Health
Affairs, July/August 2000, pages 139-148, are available from PNHP at (312)
Kip Sullivan is a health policy analyst and
research director of
Minnesota COACT. His review article "Managed Care Plan Performance Since
1980" appeared in the July, 1999 issue of the American Journal of Public
Worse news... (6/13/2000)
The US Supreme Court took away from THE PEOPLE the right to sue HMOs in Federal Courts. They accept that HMOs are there to ration cae and that they can give incentives to doctors to do so. I can't believe that this is happening in America. This country now will have a three tiered system: good medicine for the wealthy, rationed bad medicine for the middle class under HMOs, and Managed Care and... almost no medicine for the poor.
Sad news... (6/9/2000)
The Republicans defeated in the Senate, 51-48, the Bill of Patient's Rights. This means that in this sick US health care system, big business will continue to make a lot of money by collecting premiums and denying treatments. Sad but eventually THE PEOPLE will win.
Good news! (5/25/2000)
The American Psychiatric Association allowed for a Caucus of front line psychiatrists who work with insured patients under Managed Care. The Caucus met for the first time in the APA Annual Meeting in Chicago on 5/16/2000. The attendance was good. The APA gave support to the Caucus. We are now hoping that it will become a movement of front line clinicians working with patients under Managed Care. As a group the hope is that these clinicians will have a strong voice in what is good and proper for them and for their patients.
Universal Health Care for Maryland
The Maryland Citizens Health Initiative just published a report showing that Maryland can have a health care plan for all and save money in the process. They mentioned two possible plans. The first, similar to Medicare or the Canadian System, everyone would be covered by a single health plan run by a government agency. Private insurance will not be needed, unless people wanted to buy policies for services not covered, such as eye glasses, orthodontia or cosmetic surgery. In a second option, a Canadian style single payer would be in place, but private companies could opt out and keep their health coverage as is. Take a look at www.healthcareforall.com.
Hmmm.... so doctors have to lie now?
Recent studies shows that doctors in America now have to lie and stretch the point in order to give proper treatment to their patients. The study say that 34% do so because they are torn between the demands from the dividend driven insurance companies an the needs of their patients. The worse part is that the Federal Trade Commission continues to deny them the right to get together to be heard by these for profit corporations.
Another good news! (3/30/2000)
HOUSE JUDICIARY COMMITTEE APPROVES CAMPBELL ANTITRUST BILL 26-2
This morning, in a tremendous victory for organized medicine, the House Judiciary Committee approved H.R. 1304, "The Quality Health Care Coalition Act of 1999," sponsored by Rep. Tom Campbell and 211 of his colleagues by a vote of 26-2. Rep. James Sensenbrenner (R-WI) and Rep. George Gekas (R-PA) were the only two members of the House Judiciary Committee to oppose the bill.
This landmark antitrust relief legislation would remove legal barriers and allow physicians and
other health care providers to engage in joint negotiations with health plans. The bill also
restores physicians ability to be effective advocates on behalf of their patients, while strengthening the physician-patient relationship.
Very good news!!! (3/23/2000)
The American Psychiatric Association has approved a Caucus For Psychiatrists Who Work with Managed Care Patients. The Caucus will meet the first time in the next Annual Meeting in Chicago.
This is good!
Ceo of Aetna resigns (2/25/2000)
Aetna CEO Huber resigns, replaced by Donaldson
NEW YORK, Feb 25 (Reuters) Aetna Inc. AET.N, the U.S. No.1 health insurer, named
former U.S. Undersecretary of State William Donaldson chief executive on Friday after Richard Huber resigned under mounting shareholder and customer criticism.
Shareholders and analysts blamed Huber for the company's recent poor performance and the decision not to go ahead with a plan to sell its international unit for about $5 billion.
The company has also suffered lower returns because of the the industry wide problem of rising pharmacy costs, increasing the amounts it must pay out in claims.
The company's shares fell to a 20 year low of 381/2 last week after disappointing fourth
quarter profits. They were trading at 411/2, down 15/16, after the announcement.
Aetna made no comment on Friday on any plans to restructure or spin off of its Internet health Web site unit as a way of boosting the stock price, which had been widely expected.
Donaldson, the 70 year old cofounder of investment bank Donaldson, Lufkin & JenretteDLJ.N, and a former chief executive of the New York Stock Exchange, said in a statement that the Aetna board felt "frustration at recent returns received by Aetna shareholders".
He said Aetna was conducting "an urgent review of the company's strategy and operations and will initiate a program designed to realize our full potential for present and future shareholders."
He did not say when any firm plans would be announced.
The company has particularly faced criticism from shareholders over results at Aetna U.S. Healthcare, the company's HMO business, which was formed when Aetna bought U.S. Healthcare in 1996.
Huber, 63, was scheduled to retire in November 2001.
Supreme Court will hear the case against
On February 23, 2000 the US Supreme Court will hear the case Pegram vs. Herdrich. Here is how the 7th Circuit Court of Appeals had a majority opinion: " We are far alone in our belief that market forces are insufficient to cure deleterious effects of managed care on the health-care industry". The case is simple. Cynthia Herdrich had a health insurance plan who failed to give her a sonogram soon enough to diagnose a ruptured appendicitis. Worse yet, after it this was diagnosed it told her to go to a hospital 50 miles say from her home to be operated. The lower court awarded her $35.000 but did not allow her to make a Federal Suit because of the ERISA protection for the Health Plan. The 7th Circuit Court overruled and heard the case coming to the above opinion. Now the Supreme Court will decide. This coincides with the debate in the Congress of the "Patients' Rights Bill".
What is really new?... (2/9/2000)
Just saw in TV last night. The number of applicants for Medical Schools in the USA dropped 18%. Among medical students the number that chooses psychiatry is also dropping. It is not difficult to guess why. The other day I saw a statistic showing that physicians -who were considered vet good risks for disability insurers- are now applying for disability as soon as they don't feel totally well. You know, medicine used to be a noble profession and used to attract the brightest. Now... no longer. Can you all guess why???
Very good news!!! (1/2/2000)
Happy New Years to all! I have a very good news today. The Board of Trustees of the American Psychiatric Association approved an Action Paper voted by the Assembly for the creation of a CAUCUS OF PSYCHIATRISTS WORKING WITH MANAGED CARE PATIENTS. Finally psychiatrists who work with insured patients will be able to get together to exchange ideas and information. They will be able to discuss to what extent it is possible to work with insured patients without risking the ethics of the doctor-patient relationship. Most likely next May this Caucus will convene for the first time at the APA Annual Meeting in Chicago.
The United Health Care hoax... (12/21/99)
You will see the news below saying that the United Health Care would allow clinicians to make their decisions without "managing them". I guess it was too good to be true. Look at the news that I just read:
"Medical Society of New Jersey Calls United Healthcare Policy a Sham; Physicians Denounce Shift in Policy
LAWRENCEVILLE, N.J., Dec. 21 /PRNewswire/ -- The Medical Society of New Jersey today denounced United Healthcare's (NYSE: UNH - news) shift in policy concerning pre-certification of care. After initially stating that it will give doctors the final say on medically necessary care, United Healthcare has shifted its focus 360 degrees and will now review medical decisions after all. In a December 1 document entitled ``Physicians Reference Guide,'' United Healthcare of New York/New Jersey says, ``Claims will be adjudicated retrospectively, according to a five-step process.''
``The perception was that United Healthcare was giving doctors greater freedom to decide what type of care their patients need,'' said Patricia Klein, MD, Medical Society of New Jersey. ``They pretended to be acting in the best interests of patients and physicians, but have pulled the rug out from under them.''
In November, United Healthcare -- the nation's second-largest health insurer -- announced that they would no longer require prior approval for medical tests and treatments. That meant doctors could schedule X-rays and outpatient surgery without seeking permission from the HMO. The position even received nationwide praise, including an endorsement from the American Medical News' editorial staff which stated in a December 20 editorial, ``United's action confirms what doctors have been saying for years, that a policy of second-guessing physician treatment decisions is an inefficient way to run a health plan.''
As of December 1, United is now demanding submission of all medical documentation with all Level 4 and Level 5 Evaluation & Management claims, including all office and outpatient services, consultations, and unlisted evaluation and management services. What's more, physicians must still receive pre-certification from United Healthcare for MRIs, CAT-Scans, physical therapy and other medical procedures.
United Healthcare also announced that Magellan Specialty Health is processing its claims. This out-of-state corporate claims management firm has presented great difficulties to New Jersey physicians in the past and has been dropped by other HMO's in the state, such as Horizon BlueCross BlueShield.
``Last month, United sold pipe dreams and everyone bought a ticket,'' said Irving Ratner, MD, President, Medical Society of New Jersey. ``It's time for patients and physicians to reevaluate United Healthcare's transparent promises, and see this shift in policy for what it's worth: another attempt by managed care to circumvent patients in favor of increased profits.''
Founded in 1766, the Medical Society of New Jersey is a voluntary association of 9,500 physicians statewide, whose mission is improving the health of New Jerseyans and acting on behalf of its members in legislative and regulatory matters.
To speak with a Medical Society of New Jersey representative, or for a full copy of United Healthcare's Physician Reference Guide, contact Jon Hendl at 201-964-2372".
Physicians for Responsible Negotiation Launched (11/26/99)
Physicians For Responsible Negotiation (PRN), a national negotiating (labor) organization created by the American Medical Association, announces its formal launch and its inaugural officers. PRN is now available to organize and assist eligible physicians and residents in negotiating important issues with their employers involving patient care and physician practice.
Initially, PRN will negotiate on behalf of
physicians, as well as certain resident physicians where state law
A case pending before the National Labor Relation Board, however, could
expand the number of physicians currently eligible to negotiate through
PRN. In addition, PRN will assist self-employed physicians in
such as Texas, where state law allows these physicians to collectively
negotiate with insurance plans and other payors.
The United Health Care initiative...
In a surprising movement the United Health Care, the second health corporation in the US decided to stop managing the doctors and requiring pre-authorizations for their procedures and treatments. The corporation found out that they were spending 100 million dolares managing the doctors while approving 91.9 percent of their proposed treatments and interventions. A lot of managers, reviers and alike are going to lose their jobs....
Trip do Brazil... (11/21/99)
I am just returning from a trip to Brazil. I was invited by the Medical Society of Rio de Janeiro to speak to them about US Managed Care. Many US health corporations are arriving in Brazil and creating joint ventures with local business. I gave them an idea of what is coming to them. I as pleased to learn that they are already getting together as a group to try to face the monster. In Rio there is now a "Central de Convênios" that congregates the doctors and speaks for them when negotiating with these corporations. In my presentation I was asked a question that I was unable to answer: "How come in the US, the cradle of freedom and activism, the doctors allowed this health care system to be installed in the country?". I did not know how to answer...
Now... doctors have to lie... (10/25/99)
What a great US health care system. In today's paper: "Doctors say lying OK to aid patients". Insurance restrictions cause ethical dilemma. new study concludes. A survey of 169 internists in eight cities found that 58 percent considered it ethical to lie for a patient who needed a heart bypass operation, and 48 percent considered it ethical to lie to get intravenous pain medication and nutrition for a dying cancer patient. The percentage were lower for less serious conditions. (this weeks Archives of Internal Medicine). This is the direct consequence of putting profits above patients' needs...
The Dingeel-Norwood Bill of Patients' Rights was just approved in the House. Mind you that many Republicans left the Republican Party to vote with the Democrats. This is a great victory for the American people. The millinery ads from the insurance industry did not prevent the law from passing.
Another suit (10/7/99)
Another US health corporation is also being sued. This time for not revealing to the insured how and in what conditions it pays its doctors and for given "incentives" for them to advise treatments that may not be in the patients best interests.
Law Suit (10/5/99)
An USA health corporation is being sued in the US District Court for offering cash bonuses for reviewers to deny care. In the same paper today, in Maryland one in six citizens don't have health insurance. Yesterday in the front page: :Health Care Gap Grows. The irony? In both papers (The Baltimore Sun) a full page millionaire ad from a US Health Corporation...
Isn't this interesting?
US SUPREME COURT (9/29/99)
Finally the US Supreme Court will be involved in Health Care. Never too late. The question is simple: has an American Health Corporation the right to deny care to an insured in order to increase its profits? Interesting question, no?... More specifically, it is legal for doctors to cut back in treatment to save money for a medical benefits group such as a health maintenance organization. The outcome of an Illinois case may go far towards determining how much protection federal law will offer Americans in the face of cost-cutting efforts by "managed-care" plans.
Let's wait and see what the justices will decide later this year.
Practitioner Update (American Psychological Association) July/August 1999
In early August, APA released an analysis of
profits that insurance and managed care companies can generate by
the money saved while denied claims undergo an appeals process. The
for the analysis is based on the patients' rights bill that the Senate
passed. Pricewaterhouse-Coopers found that the insurance and managed
industries could generate interest income of up to $280 million each
is as few as one percent of claims are denied and then reversed
an independent review process. Under the review process created by
insurers may avoid paying claims on services for up to 377 days, during
which time the moneys presumably are invested,
Health Insurance getting ever costlier
Health Insurance premiums, nearly flat in the
mid-1990s, continue to accelerate, with some surveys and benefit
projecting price boosts for next year approaching 10 percent. As many
set their plans for next year, a number of insurers are redesigning
benefits, with higher patient co-payments for some type of drugs, in an
effort to rein in the most rapidly growing cost factor. In addition,
are going up as HMOs seek to improve profitability.
Critics of managed are say the new round of increases, as many employers set their plans for next year, shows that HMOs can no longer control costs after having achieved someone time savings by cutting rates to doctors and hospitals and pushing care to less expensive settings. "Last year they started raising rates because they had squeezed out all the costs they could," said Melissa Gannon, vice president of Weiss Ratings Inc., a Florida company that monitors the finances of HMOs and other insurers. "They probably have pretty much used up all their tricks. They have denied as much coverage as they can deny."
Hastert Encourages Plan For Patients' Rights Limits (8/7/99)
By Juliet Eilperin and Amy Goldstein
Washington Post Staff Writers
Saturday, August 7, 1999; Page A08
House Republican leaders scrambled yesterday to cope with a growing faction of party dissidents who favor strong new regulation of managed-care plans, giving encouragement to a pair of GOP lawmakers who have drafted a more limited set of patient protections.
House Speaker J. Dennis Hastert (R-Ill.) said he backs the basic principles behind a new patients' rights blueprint unveiled yesterday that would give patients a limited right to sue health maintenance organizations for malpractice and includes several GOP-backed tax incentives to help certain people buy insurance.
While stopping short of endorsing the latest approach, designed by Reps. Tom Coburn (R-Okla.) and John Shadegg (R-Ariz.), Hastert signaled that GOP leaders will work to refine their plan and bring it to a vote of the full House when Congress returns to work after Labor Day.
The speaker's encouragement seemed designed, as much as anything, to slow momentum behind bipartisan legislation, introduced Thursday by House Democrats and a group of rebellious Republicans who say they have dozens of GOP supporters for their bill. The bipartisan legislation, sponsored by Reps. Charles Whitlow Norwood (R-Ga.) and John D. Dingell (D-Mich.), calls for significantly tougher regulation of HMOs and is opposed by the House leadership as well as business and insurance interests.
The public jockeying, just as Congress adjourned for its August recess, reflects how much pressure House members feel to pass legislation on an issue that polls indicate is of personal importance to many voters. Yet the jockeying also reflects the difficulty the House, which narrowly approved a Republican patients' rights bill a year ago, is having agreeing on an acceptable course. In the last year, the GOP majority in the House has dwindled to a mere five votes, and lobbying on both sides of the issue has intensified.
The pressure on the House is particularly great now because the Senate adopted a GOP bill to regulate managed-care plans last month. Coburn and Shadegg released their plan yesterday after negotiating with House leaders until the early morning hours, and their approach remained sketchy in several respects.
Although Republican leaders generally oppose
idea of being able to sue health plans, the new blueprint would allow
when patients had first proved through an outside appeals process that
they had suffered medical harm. It is unclear whether those suits could
be brought in state courts, or only in federal ones, and exactly what
of financial damages patients could win.
"We don't want to open up unfettered litigation," Shadegg said.
Unlike both the bipartisan legislation and the
Senate bill, Coburn and Shadegg would not require HMOs to pay for
to take part in clinical trials of new therapies. But their plan would
help patients compel their health plans to pay emergency room bills,
would make it easier for women to visit obstetrician-gynecologists and
for children to be taken to pediatricians.
Hastert yesterday said that the two lawmakers "have done yeoman's work" but indicated that House leaders and the committees with jurisdiction over health issues probably would alter their proposal.
Other Republicans disparaged the plan, however, and a few privately branded it "Dingwood Lite," a comparison with the bipartisan measure.Rep. John A. Boehner (Ohio), one of the leading Republicans on managed-care reform, emphasized that House leaders did not endorse yesterday's proposal. Boehner urged employers and insurance companies, which contend such reforms would drive up medical costs and thus leave more Americans uninsured, to step up their efforts to defeat them. "We have done everything we can to bring some sanity to this debate," Boehner said. "Now, frankly, it's up to the employers. . . . If they can't change the political dynamic in the next six weeks, it's going to be a problem."
While insurance trade groups would not critique the new plan, because it lacks specifics, they indicated they would heed Boehner's call to attack the bipartisan approach in the next month through a grass-roots campaign and advertising.
Discontent doctors and nurses in America. (7/29/99)
A new survey shows widespread discontent among doctors and nurses about the quality of health care under managed care plans. The survey was conducted for the Kaiser Family Foundation, a non profit health research group. It was done with the Harvard School of Public Health and was administered by mail to a sample of 1,053 physicians and 768 nurses between Feb. 11 and June 5, 1999. Sixty one percent of doctors said insurance plans denied coverage for a prescription for one of their patients on a weekly or monthly basis. Thirty one per cent said they experienced denials of a hospital stay on a weekly or monthly basis, and 42 percent said they had experienced denials of diagnostic tests or procedures that often. Between a third and two thirds of the doctors said that their most recent denial had resulted in a serious decline in the patient's health status, depending on the type of service denied. Almost half the nurses surveyed said they saw patient's health suffer because of decisions made by health plans. Thirty per cent of nurses - and 26 percent of doctors - said they sometimes exaggerated the severity of a patient's condition to get care they thought was necessary. (The Baltimore Sun, 7/29/99)
Big Fight in Congress: Patients' Bill of Rights. President Clinton said that he will veto the watered down Republican Pro-Managed Care Bill of Rights. (7/16/99)
Measures On Patients' Rights Lose In Senate
By Helen Dewar and Amy Goldstein
Washington Post Staff Writers
Wednesday, July 14, 1999; Page A01
The Republican-controlled Senate yesterday rejected most major Democratic proposals to strengthen the rights of patients in managed-care plans, including an initiative that would have given physicians, rather than insurance companies, the final say over patients' treatment.
On five votes that were relatively close and largely along party lines, the Senate also brushed aside Democrats' hopes of imposing federal powers that would have given new protections to every American with private insurance. It defeated their efforts to give women more freedom to pick their doctors, to guarantee payments for emergency room visits and to set up grievance procedures when health maintenance organizations deny care. A Republican proposal to allow self-employed people to deduct the full cost of health insurance from their taxes was approved.
Despite defeat of the broader proposals, the Senate signaled that it is prepared to take more modest, Republican-sponsored steps that would grant new rights to patients in certain kinds of health plans. After the voting ended last night, Assistant Majority Leader Don Nickles (R-Okla.) reiterated the GOP's contention that the Democratic approach would drive up medical costs and said Republicans plan today and Thursday to offer proposals on many of the same issues. "I think we had a very productive day," he added.
The votes reflected formidable unity among Republicans only a few weeks after they fractured over the issue of gun control, losing to the Democrats on key votes.
Yesterday's votes were a bad omen for the rest of the Democratic proposals, especially a contentious one -- favored by doctors and consumer groups but adamantly opposed by the insurance industry and most Republicans -- that would allow patients to sue their health plans for malpractice.
Even though they lost the votes, Democrats believe they scored at least a partial political victory in framing the issue for next year's elections. Complaints about HMOs and other forms of managed care have increased in recent years, giving the Democrats what they see as an opening to take an aggressive consumer protection posture.
Earlier in the day, President Clinton was on the attack, slamming
Republicans' narrower and less stringent approach, charging that it
"merely toothless and half-hearted protections."
"The people deserve a bill that protects them, not the insurance companies," he said. Clinton's advisers said this week they would recommend a veto if the Republican bill is approved by Congress. The significance of the women's health initiative, in particular, was political as well as substantive. Medically, it had two main goals: to let women in HMOs pick an obstetrician-gynecologist as their primary care doctor and ensure that doctors and patients, not health plans, have the final say on how long women can stay in the hospital after surgery for breast cancer.
This has been a relatively tangential part of the battle over managed care, but Democrats chose the initiative for their first vote, showing how deeply political considerations lie at the heart of the debate. In essence, the minority party was trying to force the GOP onto the unpopular side of an issue Democratic senators feel will play well with women.
"Today we saw what 'compassionate conservatism' pretends to be," said Sen. Barbara A. Mikulski (D-Md.), referring to the campaign theme of Republican presidential front-runner George W. Bush. "It isn't compassionate, but it is conservative."
Republicans appeared to understand the political stakes too. Before yesterday's vote, GOP leaders made clear they would have a more narrowly drawn proposal on women's health care that would not allow women to pick an OB-GYN as their main doctor, but would allow them longer hospital stays after mastectomies. And unlike the Democrats' plan, it would guarantee that both men and women can get a second opinion after any type of cancer is diagnosed.
GOP leaders said last night they also will offer alternative proposals on access to emergency rooms and clinical trials along with their own way of defining what kinds of treatment are medically necessary.
Given the lack of support for the initial Democratic proposals, it was hard to see where Democrats could pick up additional GOP backing before additional votes on amendments and the final votes on the two parties' rival bills, scheduled for Thursday. Minority Leader Thomas A. Daschle (D-S.D.) had described these early roll calls as critical "test votes."
In yesterday's votes, which were either 52 to 48 or 53 to 47, Democrats drew the support of no more than two or three Republicans on any of the five disputed proposals. Sens. John H. Chafee (R.I.) and Arlen Specter (Pa.) were among the most consistent Republican crossovers, but were joined by several others on at least one vote.
Among them was Sen. John W. Warner (Va.), who voted with the Democrats on the women's health care issue, which was sponsored by his Virginia Democratic colleague, Sen. Charles S. Robb. Warner voted with his party on the other proposals. The other Washington area senators, all Democrats, voted with their party. In what was probably yesterday's key vote, the Senate scuttled a leading Democratic initiative that would have substantially weakened the leverage of HMOs by guaranteeing that doctors, not health plans, could dictate what kinds of treatment patients need. Democrats had argued that profit-minded HMOs are cheating patients of care, while the GOP has contended that giving doctors more clout would drive up medical costs and, ultimately, cause more Americans to become uninsured.
In beating back the Democratic plan, Senate Republicans left intact a proposed grievance procedure in which patients who believe they have improperly been denied care would be able to appeal within their HMO and, if necessary, to an outside appeals panel. But the measure would not go as far as Democrats want, because the health plans could pick the outside reviewers and charge patients for pursuing complaints.
The women's health amendment dealt with two issues that many states have addressed over the last few years. Currently, about one third of the nation's OB-GYNs say they are not allowed to be primary care doctors in the biggest HMO for which they work, according to a survey last year by the American College of Obstetricians and Gynecologists. The group's latest figures, based on a 1993 survey, suggest that nearly three-fourths of women consider their OB-GYN to be their main doctor. The Democratic proposal would have overlapped a trend in state legislatures, 37 of which have adopted laws in recent years to try to make it easier for women to visit OB-GYNs. Most, however, have not gone as far as Senate Democrats wanted.
States also have stepped lately into the other issue in the
women's initiative: guaranteeing longer stays after mastectomies to
breast cancers. There is little research evidence documenting how many
women are having such surgery on an outpatient basis or suggesting that
women have been harmed by going home too soon. And some politicians
started to decry what has become known as "legislation by body part."
Nevertheless, the issue has become such a rallying cry recently that laws guaranteeing a minimum of two days in the hospital -- or giving patients and doctors final say over when women go home -- have been enacted in 19 states.
THE AMA IS NOW IN FAVOR OF PHYSICIAN'S UNION (06/27/99)
Yes, this is the biggest news here in America. The traditional and highly individualistic AMA (American Medical Association) is now in favor of physicians forming UNIONS. The anti-trust laws in this country will only allow this for physicians who are employed by companies. In the case of Managed Care the things was so carefully done that the physicians are not "employees" but only "associated credentialed providers". There is a law in Congress to allow these "providers" to form their union too!
Things are changing!
LETTERS TO EDITOR -- THE VIRGINIAN-PILOT
(Virginian Pilot Ledger Star; 06/04/99)
Yet another category of expendable people
Sentara Health System's decision to end its Medicare HMO coverage is an absolute disgrace. It's another example of bureaucrats deciding which members of society are expendable.
HMOs are in the business of making money; they don't want liabilities. Older Americans and Americans with pre-existing conditions are liabilities, and therefore expendable. Chart-reading "accountant" doctors sit in big offices and decide which of us should have life-saving care and how much money this takes out of their pockets.
I am an expendable member of an HMO. I am 40 years old, have two young children, pay my premiums and do not abuse what my HMO offers. But fighting my HMO for proper care has become second nature to me.
Sentara can afford seminars and breakfasts for Medicare patients. Sentara can spend money sending health-care workers to members' homes to give them "other options" for medical care.
But are these caring Sentara employees going to sit and grieve with families when Medicare patients are dying in hospitals because they don't bring in money to the system?
It makes me want to cry.
Many news: (5/28/99)
A health insurance program serving about 14,000 senior citizens and disabled people in Virginia will shut down at the end of the year, forcing its members to switch to plans that typically cost two or three times more, cover less, and saddle patients with more paperwork.
OHIO LEGISLATURE; HOUSE GETS WEAKENED **HMO** BILL
The legislation will not allow patients to sue their health maintenance organizations.
HEALTH CORPORATION DROPS 13 AREA COUNTIES
About 18,500 subscribers of a health corporation in Eastern Washington and Northern Idaho will have their insurance coverage terminated at the end of the year.
BILL PUSHES MANAGED CARE TO FULL DISCLOSURE
Responding to rumors that a Managed CAre private managers are paying $800,000 executive salaries, diverting money to related companies, and hiring members of politicians' families, the Senate in Tennessee passed a measure requiring extensive disclosure.
**HMO** ordered to pay for care.
Federal regulators have overturned care denial decisions of an Oklahoma **HMO** at a higher rate than any other established **HMO** in the nation.
Curing HMOs / Employers explore options/
Massachusetts HMOs are raising rates to compensate for millions of dollars in losses last year, and experts say it won't be long before the losses also start to drive down benefits. HMOs have said they're increasing premiums an average of 5 to 10 percent this year.
**HMO** shows profit but cuts drug benefits
A Health Plan earned a $20.5 million profit last year from its Medicare business in Massachusetts, raising questions about why the insurer cut drug benefits this year for thousands of elderly or disabled subscribers.
New International Designation Promises Benefits to Ontario's Mental Health and Addiction Systems The World Health Organization presents Ontario's Centre for Addiction and Mental Health with the prestigious Centre of Excellence designation.
Labor official says no to union for doctors
An attempt by hundreds of New Jersey physicians to form the nation's first union for doctors has been rejected a second time by a top federal labor official.
Elizabeth Dole Keynote Speaker at 4th
**Managed Care** Conference in
The land of the "free"... (5/26/99)
Here in America, the health corporations are taking over the medical "market" and physicians really have no choice but join them as "providers" for their "customers". They are now merging and becoming a powerful small group. The antitrust laws don't seem to apply to them. Every time the physicians try to organize to face these growing monsters they are threatened by the US antitrust laws.
Now the NLRB official rules that doctors who
HMOs can't unionize. A federal labor regulator on 5/24/99 rejected a
by 650 New Jersey doctors to unionize to try to fight back the HMOs
on their practices. Dorothy L. Moore-Duncan, the National Labor
Board's regional director in Philadelphia, said the doctors cannot
because they are
independent contractors, not employees of the HMO, AmeriHealth Inc.
Look what is happening... (05/13/99)
Consolidation Changing Managed Care Landscape
NEWTON, PA. (May 13) BUSINESS WIRE -May 13, 1999-- Top 4 companies cover 30 percent of HMO lives, Scott-Levin reports
Top Four Corporate HMOs Company Covered Lives
Kaiser Permanente 8.7 million 9.3 million
United HealthCare 5.4 million 7.1 million
Aetna U.S. Healthcare 4.6 million 6.4 million
Cigna HealthCare 5.3 million 6.0 million
SOURCE: Scott-Levin, Integrated Managed Health Care database, 1998 summary
High-profile mergers have cut the number of corporate HMOs 35 percent since 1995, from 20 to 13.
Also, the percentage of regional HMOs that now are part of a larger corporation increased from 45.7 percent in 1997 to 53 percent in 1998, reports the pharmaceutical consulting firm Scott-Levin.
As a result, the top four corporate HMOs now cover 28.8 million lives, or almost 30 percent of all HMO-covered lives in the nation, according to Scott-Levin's Integrated Managed Health Care database.
Major recent mergers in the managed care industry include Humana's purchase of PCA Family Health Plans, Coventry Health Care's acquisition of Principal Health Care, and Aetna U.S. Healthcare's purchase of NYLCare.
Grandiose People (05/12/99)
How grandiose can people be? Now the Managed Care Corporations in the USA want to go worldwide. Take a look here and see how they are good at organizing themselves and ready to take over the "health markets" in other countries like Malaysia, Thailand, Indonesia, India, Philippines, Brazil, Chile and Argentina.Look how they say that US Managed Care is being adopted "all over the world". Funny!
TAKE A LOOK (05/12/99)
IMPORTANT LAW! (05/01/99)
For-Profit HMOs Invading Latin America With Help From World Bank (04/20/99)
Aetna, CIGNA Expanding South of the Border, New England Journal Study Finds
Some of the nation's largest managed care companies have started looking south in search of greater profits, according to a study in this week's New England Journal of Medicine. Unfortunately, say the authors, they're bringing their problems with them -- like "cherry picking" healthy patients, increased bureaucracy, and reduced access to health care for vulnerable patients.
In contrast to the United States, most Latin American countries have social security systems that include health care benefits. They also have free public hospitals and clinics, and, while spending far less on health care per capita than the U.S., have achieved important successes, such as improving infant mortality and life expectancy.
"Two factors are leading to the rise of managed care in Latin America," according to Dr. Howard Waitzkin, co-author of The Exportation of Managed Care to Latin America and a Professor of Family and Community Medicine at the University of New Mexico.
"First, the World Bank is pressuring governments to turn health care --and their multi-billion-dollar social security pension funds -- over to the private sector, regardless of the consequences. Secondly, there is growing economic inequality in the region. With an expanding upper-middle class eager for more services, but governments forced to cut back on public spending as a condition of new loans by the International Monetary Fund, managed care executives are seeing dollar signs."
The study focuses on the growth of managed care in four countries: Chile, Argentina, Brazil, and Ecuador. In Chile, for-profit HMOs started under Pinochet's dictatorship are now partially owned by Aetna. CIGNA is also involved in managed care in Chile, as well as Brazil, Argentina, and Ecuador.
For copies of The Exportation of Managed Care to Latin America, by Karen Stocker, Howard Waitzkin, and Celia Iriart, New England Journal of Medicine, April 8, 1999, call Cindy Foster at (505) 272-3322.
Dr. Howard Waitzkin is a Professor and Director of the Division of Community Medicine, Department of Family and Community Medicine, University of New Mexico, and a co-founder of PNHP.
Dr. Celia Iriart is a Professor of Community Health at the University of Buenos Aires and a visiting faculty member at the University of New Mexico.
Karen Stocker is a graduate student in anthropology at the University of New Mexico.
BEAN-COUNTER MENTALITY MOVES DOCTORS TO
(Arizona Republic; 03/21/99)
Now is the winter of doctors' discontent. Across the United States, doctors are complaining that the era of managed health care has robbed them of autonomy, income, time, prestige - even self- respect.
"This is life in hell," says Rex Greene, a Pasadena, Calif., oncologist and president of the Los Angeles County Medical Association - and he says he's an optimist.
A growing minority is rebelling - dropping health-maintenance- organization contracts, seeking clout in professional alliances or unions, filing lawsuits, retiring early, going out on disability or moving out of markets colonized by managed care.
Consider the San Diego gastroenterologist who slapped his physician group with a lawsuit after he was fired for spending too much time or money on patients. Or the cardiothoracic surgeon from the same city who moved to South Dakota, where managed care is nearly non-existent. Or the Pasadena internist whose frustration forced him to cut all ties to HMOs.
"I have been unneutered, restored to my vigorous self," said internist Andre Ettinger. "I can take care of patients rather than having to punt the ball all the time."
Nine in 10 doctors have one managed-care contract, but recently, hundreds of physicians en masse have rejected contracts in California, Texas, Florida, Georgia and Colorado. Patients have been left to scramble for substitute doctors.
Unions, meanwhile, are competing to capitalize on physicians' frustrations. In recent weeks, the nation's fastest-growing labor organization, the Service Employees International Union, announced it would devote $1 million a year to recruiting salaried doctors - half the nation's 600,000 physicians. Such efforts would not have been contemplated a few years ago, so strongly did doctors feel that professionals couldn't be proletarians.
Unhappy physicians lament that they often are forced to take a back seat to bean counters, creating conflicts that compromise their medical mission.
A skeptic might argue that doctors have little to grouse about. Though their income increases have not kept pace with inflation in recent years, physicians still make more money than most Americans - an average of $166,000 in 1996. Some physicians have joined the corporate ranks of managed care as chief executive officers and medical directors, drawing even heftier compensation for their trouble.
Proponents of managed care argue that doctors - and patients - should not be so quick to dismiss its benefits, including holding premiums down without demonstrably reducing quality.
But the malaise among doctors persists. Jerome Lackner, a 72-year- old internist and former health director under California Gov. Jerry Brown, practiced for 30 years in San Jose and Sacramento. He had planned to work 20 more.
Instead, in September 1997, Lackner poured out his heart in a 10- page, single-spaced letter to patients, explaining why he was closing his doors to become a salaried prison doctor.
"I have not been able to accommodate to this system," he wrote.
His practice included 24 hours on call, late-night exams, free care for the indigent and counseling for alcoholics and addicts. Meanwhile, the bills piled up, and the pressure mounted to see more patients, turn away the seriously sick, squelch referrals to specialists and spend hours with paper.
"I am just unwilling to get a . . . lobotomy in order to achieve success as a doctor under managed care," he wrote to patients.
Discontent is rampant among older doctors such as Lackner, forced late in life to adapt to what one described as health care's "industrial revolution." Many younger physicians, too, confess to uneasiness about managed care.
A survey of 900 doctors, ages 40 and younger, found seven in 10 were dissatisfied with their managed-care organizations. More than half identified "denial of care" by health plans as their greatest ethical concern. More than half also reported they are making less money than they had expected.
Doctors' frustration is surfacing in ways ranging from individual resistance to organized action:
* The traditionally conservative American Medical Association is pushing a broad patients' rights agenda in Washington - including the right to sue HMOs - that has rankled leading Republicans who prefer a moderate approach.
"If we don't do anything about this, I think we will drive physicians out of practice," said Dr. Nancy Dickey, AMA president.
* San Diego pediatric gastroenterologist Thomas W. Self drew national attention when he sued his medical group, charging it had fired him for spending too much time and money on his patients. He won a $2.5 million settlement. Physicians saw Self's case as sending a loud message that monetary concerns cannot intrude with impunity on the doctor-patient relationship.
* Labor unions, though still anathema to many doctors, are stepping up their organizing efforts and seeing remarkable success. Membership is concentrated among salaried physicians in HMOs or hospitals. But some unions are picking up membership among independent doctors who hope to negotiate better HMO contracts, despite antitrust laws that limit their collective-bargaining ability.
* Doctors, once in the work-till-you-drop category, are increasingly filing disability claims, delaying their return to work after injury or simply not going back. Insurers say the overwhelming reason is dismay with managed care.
And patients have been caught in the cross-fire. During a dispute in Texas, hundreds of specialists pulled out of an Aetna HMO. The nation's largest health-care insurer responded by refusing to authorize the doctors to treat any patients in its plans. The dispute was ultimately resolved, but patients paid a price in delayed or disrupted care.
The real Medicare conflict (03/18/99)
(Times Union; 03/18/99)
The bipartisan commission on Medicare, one of those groups to which everyone likes to pass the buck but to which no one wants to pay much attention, is out of business. The shutters slammed shut with Tuesday's failure to reach a consensus at its final meeting, which ended in a nasty impasse over how to shore up the giant health plan for the elderly against the twin forces of an aging population and ever-rising medical costs.
There will be hand-wringing and hyperbole. And, for certain, President Clinton will be attacked for not having done the heavy political work.
Whatever arguments you hear, they will not be the real ones. The real conflict is larger and older in this country. We have not decided whether health care is a right or if it is a commodity to be bought and sold, like so much sugar and soybeans.
This fight has raged since President Truman's administration. It was a big reason the 1994 Clinton health-care plan foundered, although crass politics, stripped of philosophical pretense, was a big reason. The Medicare commission never did try to blunt the sharp edges of the argument, though you could say that is what commissions are supposed to do. Its leader, Sen. John Breaux, D-La., proposed a market-based medical plan for the elderly that revolutionizes the program by taking away much of what makes Medicare work for people who are insured by government only because the private market didn't want them.
Breaux's plan would not guarantee elderly people health care. It would guarantee them a fixed sum of money with which to go out and buy health care from insurance companies.
This is not inherently evil. It just doesn't accomplish what Medicare does. It doesn't guarantee benefits. It lets insurance companies decide how they are going to give you health care.
Some insurance companies might decide to pay for one or two days in a hospital for a certain surgery; others might send you to the outpatient wing. Most would probably cover prescription drugs, but it would be up to the insurance company how much to charge for them. It could reduce the limit on drug coverage from $1,500 annually to $1,000, as one big HMO with tens of thousands of Medicare patients did this year.
These are just devilish details. The bigger problem is that insurance companies would try to sign up the youngest, healthiest customers. No car insurance companies want drunken drivers. They want good drivers with good safety records who rarely make claims.
People who sell health insurance want healthy people with healthy habits who rarely need health care. In Medicare, that means new retirees in their 60s and not old, sick retirees in their 80s.
This is what the stalemate on the Medicare commission is really all about. It is a fight between those who believe in social insurance -- in sharing risk broadly so that the healthy and the sick, the affluent and the poor, share each others' burdens -- and those who believe the market should take care of this huddled mass more efficiently.
But still not efficiently enough. This is another fact not likely to get talk-time in the political eulogies for the commission. Market-care would not save Medicare from its coming fiscal straits. Not even close. The modest savings estimated from the Breaux proposal come mostly from other changes, like raising the Medicare eligibility age and making permanent some cost-containment measures enacted two years ago. Only about one dollar out of every five saved comes from the market miracle. We do not, it turns out, need to destroy the Medicare village in order to save it.
Marie Cocco is a columnist for Newsday.
A study being published by Health Affairs highlights some contradictions in the federal tax policy. It costs the Federal Government $111.2 billion last year to give employers and their workers tax breaks to buy health insurance. Most of the money was spent on families earning more than $50,000 yearly. Companies do not have to pay taxes on money spent on workers' health insurance and many employees do not have to pay taxes on their share of premiums. But Americans who pay insurance out of their own pocket get no such break.
From the Baltimore Sun (3/8/99)
CARTOON IN THE BALTIMORE SUN (02/10/99):
VERY GOOD NEWS!!! (12/13/98)
The Board of Trustees of the American Psychiatric Association voted this week-end (12/12-12/13/98, unanimity) to support the Ad Hoc Committee to Defend Health Care "Call to Action". Needles to say I am becoming proud of being a Life Fellow in this Association!
UNITED NATIONS DECLARATION OF HUMAN RIGHTS
50th anniversary of human rights declaration
December 10, /998
NEW YORK (Reuters Health) -- The Universal Declaration of Human Rights was signed 50 years ago on December 10, 1948, and the anniversary has prompted the World Health Organization and other groups to take a new look at human rights violations.
Healthcare in particular should be established as a basic human right, according to Dr. Gro Harlem Brundtland, director-general of the World Health Organization.
Mental-Health Parity Or Parody?
[Medical Tribune: Internist & Cardiologist
1998. (c)1998 Jobson Healthcare Group]
Long regarded as the forgotten step-child of
health-care industry, the country's mental- health services have
been upgraded with the newly passed budget and the previously enacted
Health Parity Act, which went into effect at the
beginning of this year.
But despite these positive steps, the reality remains grim for the mentally ill.
On the surface, mental-health care has had an excellent year. The parity act, passed in 1996, requires employers to set annual and lifetime coverage limits at the same level as for physical ailments.
And the new budget for next year increased funding for the National Institute of Mental Health by $112.4 million, block grants for mental health by $13.4 million and funds for the Children's Mental Health Services Program by $5 million.
"It's been one of the best years in recent memory," said William Bruno, associate director of government relations for the American Psychiatric Association (APA). "With this funding, psychiatric research will be able to double in the next five years."
But that's where the good news ends, because while mental-health research appears ready to explode on many fronts, the actual delivery of mental-health services to the millions of mentally ill patients who need it is as shoddy as ever.
The Mental Health Parity (or parody) Act, while requiring equal coverage limits by employers, does nothing to ensure that health-insurance companies and managed-care plans allow patients to receive the full amount of treatment recommended by their doctors. "We're seeing that parity is critically important, but in managed care, there are ways to get around that," Bruno said.
Jay Cutler, director of government relations for the APA, agreed. "Parity does not address a doctor deciding medical necessity versus some bureaucrat in an HMO," he said.
In other words--just like before the parity act--a doctor may want to see a patient five or six times to treat his or her depression, but the patient's managed-care plan will only cover three visits. Or a doctor will be forced to prescribe a cheaper anti-anxiety drug instead of a more expensive one.
This is too bad, because a spate of recent reports indicates that it is unwise, both physically and economically, to skimp on mental-health care.
Health/disability insurance leaves you at
JANE BRYANT QUINN
I'M WATCHING a video, recorded In February 1997 for training purposes by Aetna U.S. Healthcare, one of the nation's largest health insurance companies. It should scare everyone who has company-paid health or disability insurance. You're at more risk than you think of not jetting the care you need.
Under current law, most patients in most states cannot sue their company plan for damages. Too bad if you die because your plan delayed or denied treatment. Too bad if you're refused disability benefits you should have had. The plan isn't liable. It's protected from damage and malpractice suits by the federal ERISA law (the Employee Retirement Income Security Act of 1974).
ERISA wasn't aimed at claims against health and disability plans. The shield against lawsuits was an unforeseen consequence of other language in the law. But the insurers love it and aren't about to give it up.
Some members of Congress tried to break the shield last year, on patients' behalf. Opponents trounced them by demonizing "greedy" lawyers and threatening that lawsuits would render health care unaffordable.
Having the right to sue for damages might, indeed, raise health insurance premiums. The Congressional Budget Office believes it could add l.2 percent to the cost of the average employer-sponsored plan.
But what's the cost of not being able to sue?
You'll find some answers on the Aetna videotape. A panel of lawyers addresses a roomful of analysts whose job it is to evaluate long-term disability claims. If the analyst thinks you're not sick enough, he or she can recommend that you not be paid.
Right off the bat, Aetna's lawyers explain that there are two classes of claims - ERISA (covering most employee plans) and non-ERISA. Non-ERISA patients still have the right to sue. The non-ERISA group includes' people who buy their own health insurance because they don't have a company plan, employees insured through a church or government entity, and employees in Texas, thanks to a recent state law (Aetna is challenging that law).
Two federal circuit courts have allowed all employees to sue in nine states: Delaware, New Jersey, Pennsylvania, Colorado, Kansas, New Mexico, Oklahoma, Utah and Wyoming.
Because of this risk, Aetna investigates non-ERISA cases with extra care. Says attorney Art Palmunen on the tape: "As a practical matter, you really may have to do more on a non-ERISA plan to protect against some of those- the exposure - (indiscernible) we're talking about.
Bays attorney Jeff Blumenthal: "We have an obligation, particularly in a non-ERISA context, to do what's called a reasonable investigation" - meaning that Aetna has to gather sufficient evidence to judge the claim. If it hasn't done so, and wrongfully rejects a non-ERISA claim, it could lose in court.
ERISA claims are another story. The tape shows that, instead of gathering evidence itself Aetna tells the sick person to handle it. If he or she doesn't present exactly the proof Aetna wants, or presents it after the final deadline for claims, too bad.
The company may bend the rule in "extenuating circumstances," Blumenthal says. Still, these tough practices are laid out only for ERISA claims. The insurer has little to lose. If you're wrongfully rejected, you can't sue for damages in court.
On the video, some of the claims analysts - the people who actually work the cases - complain that Aetna hasn't been taking enough care.
For example, here's "Barry," a 24-year Aetna veteran and 12-year disability claims analyst: Aetna, he says, used to investigate practically all of its cases before deciding whether to pay. Now, it investigates only a tiny percentage. The analysts' caseloads are four times those of other insurers, Barry says. "'The question is having the time to go out and investigate and work up that file the way it's supposed to be. "
This video was used in a court case in Anchorage, Alaska. At Aetna's request, the Judge sealed the tape. It was unsealed with the help of U.S. Rep. Lloyd Doggett, a Texas Democrat.
Says Jamie Court, director of Consumers for Quality Care in Santa Monica, Calif., "This is the smoking gun that shows insurers make denials based on money, not strictly medical determinations."
Aetna spokeswoman Joyce Oberdorf would initially answer questions only in writing. She wrote that the interpretation of the videotape is inaccurate, but, because of the misperception, Aetna would change its system for reviewing disability claims. "It is Aetna's policy to require disability claims analysts to give a full and fair review to all claims - whether governed by ERISA or state law," Oberdorf wrote.
Later, she did say that changes occurred last week, but she isn't sure how they'll affect claims.
Bottom line, no big-picture change. As long as Congress prevents you from suing for damages, insurers have an incentive to turn you down.
Washington Post Writers Group
The Sun: Monday, November30, 1998: Page 7c
Managed Care Proponents Spend $60M (11//30/98)
WASHINGTON - The Associated Press: Insurance companies and their allies in the fight against new regulations for managed health care spent an average $112,000 per lawmaker to lobby Congress in the first half of this year.
The $60 million lobbying outlay was four times the $14 million-plus spent by medical organizations, trial lawyers, unions and consumer groups to press for passage of the so-called Patients Bill of Rights, disclosure reports filed with the secretary of the Senate show.
Not all of the money went for lobbying on managed care, because many groups opposed to the changes also talked to members of Congress about other issues. Lobbying reports do not break down spending by issue.
The $60 million lobbying tab is enough to pay salaries of everyone in the U.S. transportation secretary's office or finance for almost two months the childhood immunization program of the Center for Disease Control and Prevention. It's 50 percent higher than the $40 million that tobacco interests spent between January and June to kill legislation to raise cigarette taxes to curb teen-age smoking.
The figure does not include $11 million spent on advertising against the managed care legislation, nor millions of dollars in campaign contributions that opponents of new regulation made in the just-concluded congressional campaigns.
"It certainly does show that the industry spared little effort to try to defeat patients' rights that are so popular all across the country,'' said Ron Pollack, executive director of Families USA, a health-care advocacy group.
Dan Danner, chairman of the anti-regulation Health Benefits Coalition, said the money was well spent.
"We didn't have legislation pass in the last Congress, and that was our objective,'' said Danner, also vice president of federal relations for the National Federation of Independent Business, the small-business lobbying group.
The proposed regulations, which would govern health plans known as
care or health maintenance organizations, are supposed to give patients
more power to challenge decisions about their care.
rally in Washington DC on 11/17/98 and my bumper sticker...(Click)