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
-- Pay both the cost and administration of vaccines recommended for
-- 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:
SOURCE California Medical Association