Treating patients out-of-network
By Sandra Lee Breisch
Long before 560 Dallas-area physicians in the Genesis Physicians Practice Association (GPPA) terminated their HMO contracts with Aetna U.S. Healthcare-and the insurer retaliated by cutting off their access to some 38,000 of Aetna's PPO/POS patients last summer-orthopaedists in the group got savvy.
In November 1997, GPPA orthopaedists joined Orthopaedic Surgical Associates of North Texas, OSANT, an orthopaedic IPA. Today, they are 90-members strong and prepared to deal with Aetna, if and when a favorable contract crosses their desk. Other Dallas orthopaedists who joined the group include those in IPAs at Baylor Medical Center, Presbyterian Health Care System, St. Paul Hospital, Medical City Dallas and Columbia HCA Medical Center in Plano, Texas. Their coverage includes all of the Dallas Metroplex area.
As of this writing, OSANT has no contracts. They expect this situation to change soon because most of the orthopaedists ousted from Aetna are providing out-of-network services to many Aetna members. It costs the insurer and the patient more if the patient decides to remain with their doctor. Aetna has 300,000 members.
"Aetna is calling us every week," says orthopaedist Charles E. Cook, MD, president and founder of OSANT, "We tell them the things we need [for a good contract]. We'll probably cut a deal."
Past disputes in Aetna's "all products" contracts, which required physicians to sign contracts with all or none of its health plans, evolved around the physicians' complaint that the insurer failed to provide them with clinical and financial data needed to track medical costs. Other issues involved problems with 17 provisions in Aetna's contract language which the Texas Medical Association found confusing, offensive and legally misleading or questionable. The contracts were terminated October 10, 1998.
But the picture doesn't look bleak for orthopaedists. "Aetna can't deliver orthopaedic health care in this market without OSANT members," says Dr. Cook. "Sure, there are plenty of orthopaedists outside this network, but they're not the ones insurers want to see."
Ralph Turner, MD, chairman/president of GPPA and Genesis Physician's Group, a 1,200-member IPA, said, "Apparently, there's a big deficiency of orthopaedists .They're [Aetna] is going to move [to contract with] these orthopaedists which will probably be a big promotion for them [Aetna]."
"By orthopaedists participating in OSANT," Dr. Cook says, "we can work together to preserve access to our patients and provide the least costly care." He says OSANT is working to standardize their information quality system to collect disease management data.
Explains orthpaedist Robert Scheinberg, a member of both OSANT and GPPA IPAs, "the object of OSANT is to try and provide quality orthopaedic care and decrease overutilization and be able to have a uniform voice for the orthopaedic surgeons when it comes to contracting and patient care. We don't want us to turn out to be like California or Florida where Medicare reimbursement is considered a good contract."