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Aetna settlement may be standard bearer for improved managed care consumer protection

April 11, 2000
Lisa McGiffert, (512) 477-4431

Aetna settlement may be standard bearer for improved managed care consumer protection
But physician groups compliance with agreement still voluntary

AUSTIN, TX — A major settlement announced Tuesday involving Aetna — the largest managed care insurer in Texas — could set a standard among managed care companies that improves protection for consumers and healthcare providers, Consumers Union said today.
Details of the settlement are being disclosed by Attorney General John Cornyn in separate news conferences in Dallas and Houston. The lawsuit against Aetna was initiated by former Attorney General Dan Morales, but settled by General Cornyn.
Lisa McGiffert, senior policy analyst for Consumers Union, said the settlement has the potential to significantly improve access to care for enrollees of Aetna managed care plans, as well as those of other plans. “Because of Aetna’s size and scope in the market, the agreement may help set a standard for other managed care companies to follow,” she said. “General Cornyn deserves credit for holding the company’s feet to the fire and helping improve the quality of care for many Texans.”
The settlement contains a multitude of improvements for Aetna enrollees. Among the key ones are:
· giving more enrollees access to the state’s independent review process;
· creating an ombudsman to assist enrollees with complaints and problems;
· ending financial incentives to physicians that can create disincentives for care;
· more clearly defining medical necessity and assuring that medically necessary care is delivered;
· helping people with chronic and life-threatening illnesses with enhanced continuity of care and simpler access to specialists and to experimental treatment.
One of the stickier issues in enforcing the agreement is that much of the control over denials of services and payments to doctors lies in the hands of physician groups that assume risk from the health plans. Those physician groups employ many of the tactics that Aetna has now agreed to stop. The AG has attempted to protect consumers covered under these physician groups, but physician group compliance with this agreement is only voluntary. The AG has attempted to address this issue through improved information to consumers. “As a consequence of the AG’s settlement, enrollees at least will be notified of the practices their physician group is using to pay their doctors,” McGiffert said. “If the physician’s group refuses to notify its enrollees, Aetna will inform them of that refusal.”
While the final proof of the settlement’s significance can only be measured over time, a strong component of the agreement includes regular reports to the AG to monitor its effectiveness. “Accountability is the key to making sure these changes actually translate into better care and services for consumers,” McGiffert said. “It will be critical for the results of this monitoring to be presented regularly to the public.”
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