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32 California HMOs Reject Gag Rules; Plan To Remove Them From Contracts

MANAGED CARE May 1996. © MediMedia USA
News and Commentary

32 California HMOs Reject Gag Rules; Plan To Remove Them From Contracts

The American Medical Association's January attack on so-called physician "gag rules" has been embraced by a number of HMOs since U.S. Healthcare came out in favor of minimal restrictions. Most recently,32 California HMOs have advocated open and unrestricted communication between physicians and patients about medical conditions and insurance issues such as reimbursement.

"Doctors have the obligation to communicate clearly and openly with their patients," says Arthur Southam, M.D., president and chief executive officer of CareAmerica, which has about 230,000 members.

The California Association of HMOs (CAHMO) has developed guidelines for patient-physician communication that members such as Aetna, PacifiCare, Cigna and Health Net say they will follow. AMA lawyers claimed that Aetna and Cigna contracts contain gag rules; both companies deny it.

Clauses that impede physician-patient communication won't be deleted from contracts immediately. CAHMO members have hundreds of agreements with physicians in California.

As these contracts come up for renewal, the HMOs will inspect them to determine whether they violate the announced guidelines, says Alan Tomiyama, spokesman for CAHMO.

During the past three years, pharmaceutical companies laid off thousands of detailers to reduce costs and shifted attention to decision makers who control drug formularies at managed care organizations.

That strategy is slowly changing. Some manufacturers are increasing their sales forces to target the increasing number of physicians who contract with managed care organizations, says a study by the consulting company Scott-Levin Associates of Newtown, Pa.

Product promotion to physicians working with managed care organizations has jumped 40 percent in three years, while detailing to physicians without managed care ties has dropped nearly 50 percent.

Drug manufacturers continue to detail pharmacy decision makers at managed care organizations, but are realizing that physicians still exercise choice among competing products on a drug formulary.

Not too long ago, drug company executives thought they could reach managed care by marketing to a relatively small number of influential pharmacy executives, says Joy Scott, CEO of Scott-Levin. "Companies are learning, though, that physicians are quite independent in their prescribing habits."

Not so well known as the NCQA, the Medical Quality Commission is also an accrediting body, but unlike the National Committee for Quality Assurance, which accredits health plans, the commission accredits medical groups.

An independent panel of health care professionals spends about two days visiting physicians' offices and surveys them in 14 areas that include 152 standards.

The nonprofit organization, established in 1991, has accredited 26 medical groups, predominantly on the West Coast. Recently, the commission decided to begin accrediting independent practice associations that provide some form of capitated care.

Officials hope to move beyond their California base and become recognized as a national accrediting body.

— Paul Wynn

MANAGED CARE May 1996. ©1996 Stezzi Communications