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Health Care Reform:

Health Insurance & Affordable Care Act

Aetna HMO Settlement Could Bring Broad Changes


But Bloche said there is a downside to giving doctors more flexibility in billing.

"Physicians will be able to succeed in getting higher fees from the company, and those higher fees are going to be passed on to employers and to consumers in the form of higher health care costs that don't translate into higher quality of care," he says.

The settlement calls for several other significant changes in the way Aetna U.S. Healthcare does business, including the following:

  • Ensuring that doctors determine what's medically necessary for the patient, not the plan.
  • Creating an ombudsman's office within Aetna to serve as the patients' advocate.
  • Improving patients' access to specialists inside and outside of Aetna's network.
  • Providing doctors financial incentives to offer preventive care.
  • Giving consumers at least 90 days' notice if a prescription drug is being dropped from coverage.

"The agreement provides many much-needed improvements," says Texas Attorney General John Cornyn. "This agreement takes the surprises out of managed care." After taking months to negotiate, the Aetna agreement is effective immediately, the state attorney general?s office says.

Aetna U.S. Healthcare may eventually put the provisions of the agreement in place in its other plans nationwide. "The company is in the process of studying the feasibility of these new initiatives in other markets outside of Texas," Arthur Leibowitz, MD, Aetna U.S. Healthcare?s chief medical officer, says in a statement.

Texas also filed suit against the Pacificare, Humana, and NYLCare managed-care plans, and those lawsuits are still pending.

Cornyn has instructed his staff to go after similar deals with the remaining defendants. Even if other HMOs in Texas and around the country adopt similar changes, they?ll still be facing the threat of Congressional action on a "patient bill of rights," a number of class-action lawsuits, and a pending case in the U.S. Supreme Court over how HMO doctors are compensated.

One health-care expert tells WebMD that Aetna had little choice but to agree to the settlement.

"They [the HMOs] were going to lose the power to control the docs anyhow, and instead of just letting it slip away from them, they said, 'Why don't we make a public relations coup out of it?'" says Uwe Reinhardt, Ph.D., a health care economist at Princeton University.

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