A handful of Cincinnati's best-known medical specialists have launched a legal battle against one of Ohio's biggest managed care health plans over who controls access to patients.
Two related cases - one filed last month in federal court and one filed Wednesday in state court - will be closely watched because they strike at the heart of a long-running power struggle between doctors and health insurers.
"For a long time, physicians have taken issue with the fact that some health plans seem to be rather arbitrary about who is included or excluded from their panels of providers," said Russell Dean, executive director of the Academy of Medicine of Cincinnati.
The lawsuits claim that Anthem Blue Cross and Blue Shield wrongfully dumped several prominent Tristate physicians from its networks, even though they had agreed to see patients at the insurance company's rates.
Anthem officials issued a prepared statement about the litigation, which said the doctors involved in the case are still members of some, but not all, Anthem health plans.
"Anthem's physician and group contracts allow for termination without cause by any party with proper notice," the company stated. "As Anthem builds and manages its physician networks, it must have the ability to make changes that are in the long-term best interests of its members and customers."
Anthem officials declined to elaborate.
The dropped doctors include knee surgeon Dr. Frank Noyes and four other partners in Cincinnati Sportsmedicine & Orthopaedic Inc.; foot specialist Dr. James Sammarco; and three neurologists from the Mayfield Clinic & Spine Institute, Drs. Luis Pagani, Christopher Kircher and John Feibel.
The suit by Drs. Noyes and Sammarco was filed Wednesday in Hamilton County Common Pleas Court. The Mayfield Clinic doctors sued July 7 in U.S. District Court. All the doctors are represented by one of Cincinnati's most prominent lawyers - Stanley M. Chesley - and his associate Janet Abaray.
For several years, managed care advocates have claimed that American medicine is swamped with specialists who charge excessive rates for care that in many cases can be provided safely by generalists - whom the insurers call primary care physicians.
As managed care plans have gained influence, many specialists have taken dramatic pay cuts. Some have found themselves completely dropped by plans that say they have more than enough specialists to serve their members.
In response, physicians have claimed that the trend against specialists threatens the overall quality of medical care. So for several years, doctors groups have been pushing for "any willing provider" laws that would require insurers to accept doctors who agree to the company's payment rates.
In Ohio, such legislation has been blocked by stiff resistence from the managed care industry and from large employers. Now, doctors are turning to the courts.
"This case is a common law application of the any willing provider concept," Ms. Abaray said. "Basically, what's going on is that Anthem has eliminated some of the best physicians in town without cause. As a result, they have disrupted the physician-patient relationship."
Anthem is one of Ohio's biggest health insurers, providing coverage to more than 300,000 Tristate residents and nearly 2 million people in Ohio. Its clients include Procter & Gamble, Cincinnati Bell and GE Aircraft Engines.
Ms. Abaray said Anthem won some of those lucrative contracts in part because the company boasted about its large panel of top-flight doctors. Then, after issuing public assurances that it did not plan to reduce its physician networks, Anthem dropped several of those big-name doctors.
While many health plans do business in Cincinnati, losing business from Anthem can hurt. "It's a pretty big hit to any doctor in Cincinnati if all of a sudden, you can't see Cincinnati Bell, GE or P&G employees anymore," Ms. Abaray said.
