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Playing Nice

Brad Cain, for Health Plan Insider, November 7, 2007

Always more a marriage of convenience than anything else, the social and legal contracts between health plans and providers are hitting on rough times. In high-profile cases from the East to the West Coasts, providers are fighting back and are enlisting the help of state officials to rein in the actions of insurers.

In the Golden State--long a test bed for new approaches to managed care--regulators ordered the state's largest network model health plan to drop a controversial clause about provider confidentiality during contract negotiations.

At issue for providers was a condition in the agreement that would allow Blue Cross of California to refuse to negotiate with the attorney or consultant hired by a provider and instead opt to negotiate directly with the provider. Providers also objected to the limitations on free speech the agreement imposed on them, but not the health plan. Hospitals and physicians cried foul, and with 20 major hospital contracts in danger of not being renegotiated, the state stepped into the dispute. The California Department of Managed Health Care earlier this month ordered Blue Cross of California to stop requiring acceptance of the confidentiality clause as a condition for opening contract negotiations.

In New York, meanwhile, Cigna Corp. came to an agreement with the New York Attorney General's office to revamp its physician rating system and to give members more information about how the ratings are created. The agreement is touted as a model for physician rating systems nationwide.

New York Attorney General Andrew Cuomo had taken a hard-line stance earlier this year against Cigna and the ratings plans of two other insurers--Aetna and UnitedHealthcare. In a July letter to United, Cuomo maintained that the insurer's quality-rating program "would have a strong likelihood of causing consumer confusion, if not deception." Cuomo was referring to a physician rating system that had generated such a firestorm of physician opposition in Missouri that the program had to be pulled off the market.

Under the deal with New York State, Cigna's program going forward will clearly identify the degree to which a physician's ranking is based on cost, and the system will have to include risk adjustments to ensure an accurate comparison.

The insurer also agreed to disclose more information to members and physicians about how the program is designed, how physicians are ranked and how those ratings can be appealed.

Are these latest dust-ups just outliers? Isolated examples of plans and providers seeking to redefine the terms of acceptable behavior? Or are they indicative of a stronger pushback by providers? I'm interested in hearing your perspectives on the issue. Drop me a line if you have an opinion on the subject.


Brad Cain is editor of California Healthfax and executive editor for managed care with HealthLeaders Media. He may be reached at bcain@healthleadersmedia.com .

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