BY TIM BONFIELD
The Cincinnati Enquirer
After years of frustration with managed care health plans, doctors are starting to draw a line in the sand.
"This is what doctors in other cities should have done a long time ago," said Dr. James Lang, a Cincinnati internal medicine specialist. "They should have taken a stand instead of letting terms be dictated by large bureaucracies."
This month, about 20 Cincinnati-area obstetricians and gynecologists made headlines locally and in national medical trade journals when they decided to stop treating Aetna U.S. Healthcare patients rather than sign a contract they considered unfair.
The doctors raised several complaints about Aetna's new Women's Health Program and its recent efforts to get doctors to agree to "all product contracts." For example, the new Women's Health Program requires ob - gyns to fill out more referral forms, seek pre-admission certifications in more situations and use billing codes that are unique to Aetna.
Aetna officials say the level of discontent has been exaggerated. But Tristate doctors say the dispute goes well beyond a handful of upset ob - gyn specialists. Hundreds of Greater Cincinnati doctors -- from many specialties -- still have not signed Aetna's new contract. Some say they never will. These doctors say they will continue treating Aetna patients under terms of the previous contract until Aetna changes its offer or decides to kick them out.
"This is an effort to prevent a domino effect from occurring with other plans," Dr. Lang said. "At least at this point, I'm going to stand on principle and not sign it."
The ob - gyns say agreeing to Aetna's terms would invite other, bigger managed care plans to try similar tactics.
The contract dispute has simmered largely behind the scenes for a year. When, or whether, Aetna will decide to force the issue with unsigned doctors remains unclear. Negotiations continue. And there are no deadlines.
For Aetna, a large but not dominant player among Cincinnati managed care plans, the timing of its new contract couldn't have been much worse.
The rapid growth of managed care health plans -- now estimated to cover at least 65 percent of Tristate residents -- has earned credit for curbing years of relentless health cost inflation.
But a nationwide backlash against managed care has emerged around concerns that those savings were achieved by burdening doctors with red tape, pushing hospitals to make questionable budget cuts and taking choices away from consumers.
The managed care industry now finds itself battling a wave of reform efforts that has moved from state legislatures to Capitol Hill, where Democrats and Republicans are jockeying to write their own versions of a health care "Bill of Rights."
Meanwhile in Ohio, doctors and employers have been upset with Aetna over allegations that the company has been slow paying claims. Last year, billing complaints from doctors had become so numerous that in February, the Ohio State Medical Association (OSMA) stepped in to try to settle the issue.
Now enter "The Aetna Contract."
In May 1997, Aetna mailed new contract proposals for 1998 to its primary care physicians. Specialist contracts were mailed in August. The contract was so controversial that some Tristate doctors picked this one as the first they had refused to sign in years.
"It started last summer and ran into the fall. We were getting a lot of complaints about the Aetna contract," said Nancy Gillette, an attorney with the OSMA. "The doctors perceived some of the provisions as interfering with their medical decision-making ability."
In Cincinnati, the dispute became public once several prominent ob - gyns decided to drop out of Aetna's network, including Dr. Molly Katz, president of the Academy of Medicine of Cincinnati.
Doctors have long been frustrated with managed-care red tape, but the Aetna dispute moved relations to a different level, said Russell Dean, the academy's executive director.
"This is the first time so many doctors took this kind of action all at once. Whether this is a bellwether for things to come remains to be seen," Mr. Dean said.
At least several hundred Tristate doctors -- Aetna would not reveal exactly how many -- have yet to take action on Aetna's contract. Among the undecided-yet-critical: Medica Inc., a group representing 450 Tristate doctors.
In November, Medica urged its member doctors not to sign the Aetna deal after citing nearly 30 objectionable contract terms. While Medica has agreed to deals with several other managed care plans, Aetna has taken an unusually hard line in talks, said Medica President and Chief Executive Bruce Henderson.
"Physician groups are no longer interested in adversarial, dictatorial, unilateral relationships with health plans," he said.
Among the concerns:
Basic contract wording that doctors consider too one-sided. For example, Aetna proposed giving itself the authority to drop a doctor with 30 days' notice. But if a doctor decides to leave the network, the deal required 180 days' notice.
An "all-products" clause that requires doctors to participate in all Aetna health plans.
Aetna officials say they are puzzled by the harsh, public complaints from Cincinnati doctors. They also say the critics represent a minority of area physicians.
Aetna reports that most of the 4,700 physicians in its 28-county Ohio Valley service area have signed the new deal. So have most participating doctors in other cities nationwide.
"We have worked very hard to negotiate contracts that are fair to physicians," said Aetna spokeswoman Stacey Jones.
In fact, Aetna has added doctors locally.
Since Jan. 1, Aetna has lost 17 doctors from retirement, relocation, death or other non-confrontational issues. It also lost 18 primary care doctors and 25 specialists over contract disagreements. During the same period, however, the plan has added 80 primary care physicians and 97 specialists.
"Not everyone is going to like the terms of every business arrangement. But a majority of doctors in Cincinnati and across Ohio say this is acceptable," said Aetna's local manager, Bruce Turner.
Aetna contends that many physician concerns are based on misunderstandings. To correct them, Aetna is trying to schedule meetings with individual doctors.
"We want to negotiate these contracts with individual physicians, not in the media," Mr. Turner said.
