In a closely watched deal, Aetna U.S. Healthcare has agreed to add some modest patient protections, settling a lawsuit brought by the Texas attorney general.
The agreement settles a lawsuit filed in 1998, alleging that Aetna used financial incentives to encourage doctors to limit care. Humana, PacifiCare and NYL Care also were charged.
Aetna admits no guilt and faces no penalty. It does, however, agree to tell patients more about the financial incentives it offers doctors and promises not to offer payments linked to limiting care.
The settlement comes at a turbulent time. In February, Aetna‘s board ousted its chief executive after the stock swooned. In March, Aetna rejected a takeover from a Dutch investment bank and WellPoint Health Networks.
While the settlement affects only 3.4 million Texas customers, Aetna is considering applying some parts nationally. And prosecutors in other states are studying the terms.
Connecticut Attorney General Richard Blumenthal says his state will continue investigating Aetna‘s financial arrangements. Of the Texas agreement, he said: “We have serious concerns as to whether the supposed benefits will actually be seen by consumers.”
Aetna also promised to:
* Set up an ombudsman program to help consumers with complaints and appeals of treatment denials.
* Set up an outside review system on treatment denials, something that’s already required in Texas.
* Provide patients with information about how Aetna decides what care is “medically necessary.” And notify patients in advance about changes to its list of covered drugs, also already required in Texas.
* Let doctors who practice in small groups opt out of an “all-products” clause that requires them to accept all of Aetna‘s health plans, including the lower-paying HMO.
But consumer advocates, doctors and other prosecutors had mixed opinions.
“It’s a step in the right direction,” says Lisa McGiffert, senior policy analyst with Consumers Union in Texas.
Jamie Court of Consumers for Quality Care called the move little more than a public relations ploy: “Aetna is just trying to get some good public relations so it can sell itself off at a higher price.”