CMA: Says Dept. Of Corporations Lax In Regulating HMOs
The California Medical Association yesterday "formally accused" the state Department of Corporations of "failing to enforce laws designed to protect both patients and physicians from HMO abuse." The San Francisco Chronicle reports that the CMA's petition to the DOC may indicate "a hardening of attitudes toward managed care on the part of its rank-and-file membership" (Russell, 10/15). CMA President Dr. Jack Lewin said, "Physician contracts are not treated seriously by the HMO industry and we believe the Department of Corporations has got to step in and enforce its own laws." But DOC spokesperson Julie Stewart countered, "We are enforcing existing law. Until today we had every reason to believe a productive dialogue with the CMA was under way" (Appleby, Contra Costa Times, 10/15). DOC Commissioner Dale Bonner said he was "surprised and disappointed" by CMA's charges. "We have gone to great lengths this year to reach out to the CMA to build a constructive approach to identifying and addressing issues of great mutual concern to its members and the Department" (DOC release, 10/14).
Writs Of Grievances
In a lengthy list of complaints, the CMA accused the department of failing to enforce the state law that regulates health plan contracts with physicians, the Sacramento Bee reports. Known as the Knox-Keene Act, the 23-year-old law was designed to assure "the continued role of the professional as the determiner of the patient's health needs." But with the advent of HMOs, health plans are making medical decisions, the doctors group argues (Griffith, 10/15). The CMA said doctors now "are forced to sign contracts that hold them legally liable for medical decisions the health plan actually makes," and are held to contracts that "HMOs can unilaterally change" without doctors' consent. The CMA called on the DOC to adopt new regulations and to nullify "contracts that doctors have signed with Blue Cross of California and the Aetna health plan." The CMA also complained that health plans have "inappropriate control over patients' confidential records," interfere "with continuity of care," and refuse "to disclose how much a physician will be paid under an HMO contract" (Chronicle, 10/15).
"The reality of the marketplace is a lot different from 1975 when you could say, 'I won't participate.' (Now) if I don't have a contract with the health plans, I don't see patients," said Krieger, who said the CMA might file suit against the DOC if it "fails to respond to the petition within 30 days" (Bee, 10/15). But Walter Zelman, president of the California Association of Health Plans, "dismissed the complaints," saying, "If HMOs were doing some of the things that are implied here, that would be a problem, but they are not. It's a myth that nonmedical people in HMOs are making medical decisions" (Chronicle, 10/15). However, DOC head Bonner said his department has identified three areas of HMO abuse that it will "further explore." These include: failing to disclose their payment rates to physicians, employing physician contracts that limit doctors' breach of contract protections, and using contract language that permit health plans to "sell" a doctor to another plan at discounted rates (DOC release, 10/15).
In a surprising "shift of policy," the Chronicle reports that Krieger said the CMA "is now willing to consider" backing legislation giving patients the right to sue their health plans. "We are willing to take a look at it," he said. The CMA had previously advocated third-party reviews for resolving treatment disputes between health plans and enrollees. But the Chronicle notes that consumer groups were wary of the CMA's change of heart on the issue. Health Access' Beth Capell said, "It is odd that they didn't approach any of our organizations about this complaint. It is also striking that the medical association failed to support many of the bills in the HMO Bill of Rights." She accused the HMOs of working "hand in glove with the big medical groups" (10/15).