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[IP] Re: Insurance ????
We were just talking about things like this. Is anyone else paying attention
Michael, if you think this isn't relevant just say so. Buddy '-)
By Michael Conlon
CHICAGO (Reuters) - The American Medical Association has
told Aetna Inc./U.S. Healthcare, the second biggest U.S. managed
care company, that its policies could be depriving patients ofproper care.
In a letter sent to Aetna more than a month ago and released
Wednesday, the AMA said a contract the company uses for doctors
in Florida and elsewhere is vague and allows the company too
much leeway to deny benefits.
The company's chief legal officer, David Simon, told Reuters
that one provision of the contract to which the AMA objected has
already been deleted, and denied that the company was being
vague in the way it outlines benefits to patients andphysicians.
The exchange is the latest in an increasingly loud debate
about the direction medical care has gone. The debate has seen
members of the medical profession complaining about restrictions
imposed by profit-driven health care firms and insurance
companies who specify levels of care and providers.
Ted Lewers, a member of the AMA Board of Trustees, in a
statement commenting on the group's letter, said there was ``a
trend developing in which managed care companies with large
market shares offer one-sided contracts on a'take-it-or-leave-it' basis.''
``The companies refuse to allow negotiation, yet physicians
who sign these contracts are virtually signing away their
ability to properly advise their patients and provide the care
they believe is clinically indicated -- the very service they
entered into the contract to provide,'' he added.
In its letter, the AMA said it had received similar
complaints about Aetna from physicians in five other states. The
group said the Aetna contract in question -- in which physicians
agreed to accept Aetna-covered patients in exchange for certain
limits and guidelines for care -- is representative of others in
the managed care industry.
``We believe these contracts clearly are not in the
patient's best interest,'' Lewers said.
``These provisions completely blur the line between services
that are medically necessary and services that the plan simply
does not want to cover,'' he added.
``Perhaps most troubling is the shroud of secrecy that
surrounds the existence and impact of these provisions. Patients
as well as physicians are kept in the dark,'' he said. The
AMA said the Florida contract contains a ``gag'' clause that
could limit what a doctor may tell a patient, a provision it
said may violate state law.
Simon said the so-called ``gag'' clause was ``in no way,
shape or form'' anything like that, and in light of the comments
it had eliminated the provision from all of its contracts.
He also said the services covered are explained in detail as
demanded by companies contracting with the insurer for their
employees. He said they were spelled out in handbooks and more
information was available through an 800 number.
``Members aren't kept in the dark,'' he said. ^REUTERS@