California Medical Association Statement on CMA/AETNA Agreement Announced Tuesday, Dec. 19

    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

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