Friday, November 12, 1999

HMSA, medical coalition
at odds over health plans

Points of contention

By Helen Altonn


A new agreement proposed by the Hawaii Medical Service Association for doctors participating in its health plans is a "take it or leave it" deal that could weaken patient care, says a consumer advocacy organization.

Failing to achieve contract corrections it requested from HMSA, the Hawaii Coalition for Health has filed a complaint against the state's largest medical insurer with the Insurance Division in the Department of Commerce and Consumer Affairs.

The 1,100-member group is asking Insurance Commissioner Wayne Metcalf to order HMSA to cease engaging in unfair practices, to impose fines on HMSA and to suspend or revoke HMSA's license, said Dr. Arleen Jouxson-Meyers, coalition president.

HMSA at least should be required as a condition of its license to bargain fairly with its 2,000 participating doctors and hospitals, she said.

Cliff Cisco, HMSA senior vice president, said the health insurance company is reviewing the complaint. "A lot of what she (Meyers) says is unfounded, not based on any fact," he said.

Metcalf said he couldn't comment on the complaint, which his division is reviewing to see if it has authority to pursue under Hawaii's 1998 patient bill of rights law.

He said the division recently received several similar complaints, also being investigated to determine if it has jurisdiction. He declined to identify complainants.

The coalition claims HMSA is "engaging in unfair contracting practices and creating a business environment of coercion, intimidation and abusively exercising" the power of a monopoly, Meyers said. HMSA has about 95 percent of the market as it pertains to physicians and hospitals outside of Kaiser Permanente, so it has a buyer's monopoly, she said.

The biggest problem, she said, is that HMSA "introduced a substantially different contract under the guise of amendments to the old contract." And doctors are automatically bound to the new contract if they don't object within 30 days after receiving notice, she said.

"The worst part is they are trying to exercise power to extend the contract by three years," she said. The coalition obtained some significant changes in fighting the previous HMSA contract and had asked for one-year renewable terms while talks continued on other objectionable features.

Cisco said a three-year contract is proposed because "it's more convenient. We don't have to go through this every year. We had gone for many years with the same contract."

While some physicians oppose the longer term, others said they'd like an even longer contract, he said.

The coalition, in a letter to physicians, said it had sent HMSA nine pages of comment on Sept. 12, "all of which have been ignored except for three tiny suggestions they included."

Cisco said Meyers had an opportunity to provide input and some of it was included in the document, as well as comments from other doctors.

"We're still in the early stages of gathering information and input from physicians," he said, "We've been working with physicians around the state, different physician constituencies. We encourage them to write to us with their input."

The new contract will go into effect Jan. 31. Objections are sought by HMSA in writing before Dec. 1. Workshops are being held this month for physicians to learn about the amendments and provide feedback.

HMSA will give physicians 60 calendar days' notice of the final amendments and they will have 30 days to object. "HMSA will work to address individual concerns raised," Jim Walsh, vice president for provider services, said in a letter to physicians with information about the agreement.

"We believe the existing HMSA Participating Physician Agreement is fundamentally fair and complete, " Walsh wrote. "It articulates extensive due process for physicians and emphasizes the importance of the patient-physician relationship. ... The agreement has served physicians and HMSA well for nearly two years, and we see no compelling reason to make wholesale changes."

Cisco noted Meyers spoke positively about the contract in the past. But Meyers said the new agreement reflects a "completely different perspective. ... We feel they have monopsony power over physicians and are exercising it by giving us a take it or leave it contract."

Richard Miller, University of Hawaii school of law professor emeritus and coalition consultant, said the group believes the Insurance Division has the authority to investigate the complaint against HMSA because physician agreements can't be separated from the rights of patients.

"Patients only get what physicians are allowed to give."

He said the most glaring example is a clause HMSA refused to remove from the agreement providing that the physicians agreement takes priority if there is any discrepancy between it and a health plan member's agreement.

"Which to me says, if a patient has a right to have any medically necessary treatment but the physicians agreement puts the decision in the hands of HMSA's medical directors, then the physician's agreement governs, although medical necessity may require greater treatment," Miller said.

Points deemed objectionable
by the coalition

Among the most objectionable provisions cited by the Hawaii Coalition for Health in the old contract and amendments:

Bullet There is no "fair and reasonable" standard for eligible charges.

Bullet HMSA can amend the agreement unilaterally, simply by giving physicians notice.

Bullet Physician advisory committees are chosen by HMSA and have no decision-making power.

Bullet HMSA can terminate a doctor's participation only for "cause" but it isn't defined. The coalition says it should be defined as "a material breach of this agreement."

Bullet HMSA can take an alleged overpayment automatically from a doctor's future reimbursements without notice if the amount is less than $100 per claim.

Bullet Due process is lost in the dispute resolution process because no attorney is permitted either for the physician or HMSA at an administrative appeal. HMSA selects the arbitration service but doesn't allow the arbitrator to award costs and attorney's fees.

"All of these, in our opinion, seriously weaken a participating provider's ability to treat his or her patients and to advocate on behalf of them without fear of retaliation," Dr. Arleen Jouxson-Meyers, coalition president, said in urging physicians to register their objections.

Helen Altonn, Star-Bulletin

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