SAN FRANCISCO, Dec. 19 /PRNewswire/ -- This document is the watermark for a new relationship between CMA and Aetna. It comes after some ten years of strife between doctors and Aetna, yet it declares our mutual intention to begin anew. We are striving to create a better environment for us as physicians and for our patients. The preliminary blueprint follows six months of talks during which CMA and the health plan have crafted solutions to significant and thorny problems, including Aetna's agreement to: -- Commit to paying actuarially sound capitation rates, and immediately begin paying all capitation from the day a patient joins the health plan rather than delay payment until the patient chooses a primary care doctor, which often takes place months after enrollment. Patients who do not pick a physician will be assigned on a random basis to a doctor near their home and be allowed to immediately select a new primary care physician. -- Pay both the cost and administration of vaccines recommended for children. -- Eliminate so-called "all-products clauses" for doctors, enabling physicians to pick among Aetna plans they want to join and not be forced to enroll in every Aetna program as a condition of contracting with the health plan. -- Cease forcing doctors to take on the insurance risk for the cost of their patients' prescription medicines. This practice placed physicians in an ethical dilemma and undermined the doctor/patient relationship. Doctors must be freed from this financial conflict of interest so they can make the best medical judgments for their patients. -- Pay for the cost of new technology when CMA and Aetna agree together that it has become the recognized and appropriate standard of care. This ensures patients get the most up-to-date services, drugs and therapies in a rapidly evolving environment and provides patient access to the latest medical advances and establishes a fair reimbursement system for that care. -- Cap at $1,000 the cost of arbitration for individual doctors and small practice groups when they disagree with the health plan about contract issues. These solo and small groups have been unable to afford the expense to remedy contract disputes. -- Create a CMA/Aetna liaison group to discuss and resolve a wide range of continuing issues. This liaison panel is intended to create an alternative to unnecessary battles in the Legislature and the courts. It will allow physicians and Aetna policymakers to sit down together and solve problems. While this document sets forth very significant gains for physicians, CMA wants to be clear: This is just a first step. There is much still to be done. Among the issues remaining between us: -- Drafting universal, model contract language that will ensure fairness for doctors and stop redundant contract negotiations that waste scarce health care dollars. -- Having Aetna pay actuarially sound rates that provide patients their promised medical benefits, while protecting physicians from bankruptcy. -- Creating a definitive and fair means of resolving disputes concerning California's Knox-Keene Act, which regulates health plans. CMA seeks a court-enforced arbitration process as the most sensible way out of the current contentious environment that pits plans against physicians and their patients. Apparently for political or financial reasons, Aetna does not want to be the first or only health plan to sign on to arbitration of Knox-Keene disputes. Perhaps, an arbitration requirement needs to be accomplished through legislation. -- Addressing the rising cost of injectables, which is contributing to medical group insolvencies. Injectables include chemotherapy and other expensive intravenous therapies used to treat AIDS, cancer, systemic infections and other conditions. -- Address fee-for-service payment adjudication and appeal issues. As physicians, we did not get everything we sought and, more importantly, we did not give up anything to achieve these successes. CMA retains its right to seek further resolution for these and other problems through administrative, legislative or judicial remedies. This understanding has no impact on the federal civil RICO lawsuit filed in San Francisco against other for-profit health plans. In that case, Aetna is not being sued by CMA. However, CMA is committed to achieving an enforceable dispute resolution process. That is a central issue of our RICO lawsuit and it is not resolved by this preliminary agreement. This new relationship is a work in progress. The acid test remains whether physicians feel the changes in their practices. We ask you to check back with us in six months. NOTE: A copy of the agreement can be printed from CMA's website: http://www.cmanet.org/publicdoc.cfm/24/1/GENER/564 .
SOURCE California Medical Association