Nashville Pediatricians to Aetna & patients: "Get your wallet out "
Here comes expensive pediatric healthcare technology
from a University Center ( Vanderbilt ).The way of the future.
Medical technology is getting better.....and......
....more expensive ....time to dust off that old wallet....
HRC fits right in there with the best ....and expensive.....there is no way out.......
( well not really...there is a way out...you can go to the corner
gas mechanic to have your Cadillac fixed instead of the expensive dealer.........).
Medical inflation, here I come,
TA
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Nashville doctors wield clout over Aetna
ama-assn.org
Pediatricians' insistence that they need continued access
to a local medical center prompts the insurer to make an
unusual coverage arrangement.
By Leigh Page, AMNews staff. May 7, 2001.
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When Vanderbilt University Medical Center in Nashville, Tenn., terminated its contract with Aetna U.S. Healthcare March 1, it gave local pediatricians the chance to show Aetna that it needed them as much as they might need the insurer.
Aetna agreed to let pediatricians -- and pediatricians only -- continue referring patients to Vanderbilt at full in-network charges.
The pediatricians had decided that without access to Vanderbilt, the only children's hospital in Nashville, and its 150 pediatric subspecialists, they would have to terminate their own Aetna contracts.
After years of enduring low payments and unbending policies at Aetna, pediatricians discovered that "they needed us," said Joseph Lentz, MD, part of a seven-member group in Nashville and president of the Tennessee Pediatric Society.
All other insurers in Nashville still allow full access to Vanderbilt. Without pediatricians, Aetna would have had an incomplete network of little value to local employers, Dr. Lentz said. "The first thing families look for is their pediatrician on the list."
In the negotiations, Aetna rejected Vanderbilt's demand for a payment increase, and negotiations ceased weeks before the contract deadline. The company said the termination means 6,000 nonpediatric members would have to change hospitals or receive significantly reduced coverage at Vanderbilt.
Addressing the pediatric arrangement, Aetna spokeswoman Wendy Morphew insisted that it was standard policy for Aetna to grant full coverage for services that cannot be found within its network.
But she reported that despite many intense negotiations with hospitals in 2000 and this year, few of them have actually terminated their contracts, and the problem of access has not come up. She added that Aetna has made very few -- if any -- special coverage arrangements for a particular specialty when a hospital contract falls apart.
Aetna was fully aware of pediatricians' insistence on access to Vanderbilt. Four years ago, when Vanderbilt last sent in its termination notice to Aetna, some 24 of the 60 pediatricians in town, including Dr. Lentz, sent in their notices, too. Within days Aetna reopened negotiations, signed a new contract with Vanderbilt and the pediatricians withdrew their termination notices, Dr. Lentz said.
"We have to have Vanderbilt," said Ralph M. Greenbaum, MD, part of a five-member pediatrics group in Nashville, who said he also was ready to drop Aetna. He said children need pediatric subspecialists, such as respiratory therapists, most of whom are at Vanderbilt, and that "adult" counterparts won't do.
When the new Aetna policy started, Nashville pediatricians reported that some utilization review personnel were not aware of it when considering prior approval applications for Vanderbilt services. But Aetna has assured them that the misunderstandings have been cleared up.
Looking at their own contracts
Now the pediatricians must consider whether they want to continue their own contracts with Aetna as the insurer revamps its contracting process nationwide. In January, Aetna lifted its all-products clause, which had forced physicians to sign on to its HMO plan if they wanted PPO and other fee-for-service contracts.
Once their current contracts have expired, the pediatricians are now free to stay in Aetna's better-paying PPO and dump its HMO, which they say pays the lowest rates in the area.
"We're getting out of the HMO unless they make some changes," said Dr. Greenbaum, but he added that he had not yet started negotiations.
But Dr. Lentz, who has started negotiating with the insurer, said he probably would sign a new HMO contract with the company.
He said Aetna was offering to switch its HMO payments from capitation to fee-for-service payments pegged at 100% of Medicare payments.
Other doctors "wouldn't support that amount because they want to be above Medicare, but it's fine with me," Dr. Lentz said.
He said he could survive without the Aetna HMO contract, which represents 500 of his patients, but he would not drop it unless Aetna made no significant concessions.
"I like our office to be open to kids as much as possible," he said. Dropping insurers, he added, is "hard on the families." |
