May 29, 2000 -- In 1998, the state of Texas sued Aetna U.S. Healthcare for allegedly using financial pressure to force doctors to cut back on necessary medical care. Last month, Aetna signed a no-fault settlement agreeing to voluntarily change many of its doctor-patient policies there. The main provisions of the agreement, which could provide a model for health maintenance organizations (HMOs) nationwide, include the following:
- Doctors will no longer receive financial incentives (such as bonuses for achieving or penalties for exceeding spending targets) to limit medically necessary care. Bonuses will be allowed only for providing preventive care.
- Aetna will stop paying a set monthly fee for each health-plan member to doctors with fewer than 100 HMO members ("capitation") and instead will pay them a fee for each service.
- Aetna will create a referral process for patients who need access to specialists and will provide a company ombudsman to support customers with health insurance appeals or complaints.
- Aetna will allow external review when payments are denied for experimental and investigational coverage, emergency care, and prescription drugs.
- Aetna has agreed that doctors in Texas will determine what is "medically necessary" for patients, and that those decisions will be based on publicly disclosed state-of-the-art standards.
- Aetna must clearly disclose, before a plan member signs up, what services are not covered.
- Aetna will also end the practice of forcing patients to stop seeing doctors who have withdrawn or been dropped from its HMOs. Patients can continue to see their doctor through the end of the insurance period, even if he or she has left the plan.
Michael D. Towle is based in Chantilly, Va., and writes regularly on health and legal issues for WebMD.