PRACTICE PULSE: Despised Policy Gets Dropped

Eye on managed care.

Practice Pulse: Eye On Managed Care
Despised Policy Gets Dropped
By Gil Weber, M.B.A.

If ever a health plan had a universally despised policy, it would have to be Aetna's "all products" clause.

That provision forced providers to accept patients from all Aetna products and programs if they were to see patients from any Aetna plan. It was all or nothing. And given Aetna's market share dominance in so many cities, providers were put at an insurmountable negotiation disadvantage.

For providers whose practices received significant patient volume from Aetna, this amounted to being caught between Scylla and Charybdis. An Aetna fee-for-service PPO plan might pay reasonably well and benefit the practice. But to preserve access to those patients, the doctor could be forced to accept other Aetna products -- perhaps an HMO paying much less, and with more complicated administrative burdens and perhaps also capitated. Things were very bleak with Aetna running roughshod across the nation.

But then Aetna began to have some problems. In 1998, and then increasingly in 1999 and 2000, providers and patients started revolting. The medical and lay press reported all sorts of issues that previously had been ignored or known to just a very few.

Aetna's stock price plummeted. In February last year, Richard Huber, the CEO, was forced out, in large part over his clearly anti-provider statements and actions regarding "all products." Aetna's stubborn refusal to drop "all products" was made more difficult when some states (Texas, Virginia, Kentucky, Connecticut) banned the clauses, or effectively forced Aetna to drop the provision from provider agreements.

Almost overnight it became clear that even the 800-pound gorilla might be forced to move if sufficient pressure were applied. Then the incredible happened. The gorilla was knocked off its pedestal.

In December, Aetna announced that it was dropping the "all products" clause for all new provider agreements. Furthermore, it was going to allow providers in existing agreements to opt out of specific products by giving written notice 90 days prior to the anniversary date.

Although this certainly doesn't level the playing field, it's a positive move for the provider community. Aetna hopes this change in corporate policy will cause it to be perceived as more friendly towards providers. That remains to be seen.

Certainly, it's a public relations move, but it may be based on a fundamental change in corporate direction and a recognition (at last) that managed care, as it's been in place for the past 20 years, just isn't working for the majority of the provider community.

And it may be recognition that there's strength in numbers within the provider community. If enough eyecare providers say "no," there won't be enough doctors to care for patients. And the health plans won't be able to deliver on the products they "sell."

Of course, Aetna could throw us an unexpected curveball by paying providers at different rates for the same services, depending upon whether they accepted or opted-out of "all products." That would be an interesting ploy, particularly if the pay difference proved to be significant.

Whatever plays out, we can only hope that at a minimum this occurrence could be the start of a national trend toward more cooperative relationships between payers and providers. Now, I'm certainly not saying that this means the contracting playing field will suddenly be leveled for everyone or that all of the hassle of managed care will disappear -- believe me, they won't.

But I think this may be the start of a long overdue change given that Aetna is the biggest and most influential managed care company. Just as California is the bellwether state for the evolution of managed care in the nation, Aetna is the bellwether health plan.

Whether you provide only pri mary care vision exams and eyewear for patients or you also provide secondary care, you'll feel the impact of this change, if you haven't already. "No" is a very powerful word.