Issues
Accreditation
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Overview
Employers and other sophisticated health care purchasers are
familiar with the rigorous standards of private third-party
accreditation organizations, such as the National Committee for
Quality Assurance (NCQA) and the Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO). Private
third-party accreditation is one of the ways that employers,
consumers and others can measure the quality of a health plan. The
general public, while familiar with the term "private third-party
accreditation organization," does not understand what is
encompassed in accreditation review.
As managed care is attacked by its opponents, private
third-party accreditation is also being attacked. Opponents claim
that private accreditation is not independent, it is bought and
paid for by the industry, and government should be directly
responsible for regulating quality.
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CIGNA HealthCare Position
One component of CIGNA HealthCare's quality assurance program
is seeking accreditation by private third-party accreditation
organizations, such as the NCQA and the JCAHO. CIGNA HealthCare is
a leading organization in achieving accreditation of its health
plans.
NCQA rates managed care networks on 50 accreditation standards
in the following six categories: quality improvement,
credentialing of providers, preventive health services, members'
rights and responsibilities, utilization management, and medical
records. One hundred percent of our plnas that have been reviewed
have received a level of NCQA accreditation. In addition, several
of our health plans have received accreditation from JCAHO as part
of a pilot accreditation project with that organization.
Each accreditation organization is independent, has a governing
body composed of stakeholders, and regularly reviews and updates
accreditation standards. When a health plan is reviewed, it is
charged a fee to pay for the cost of the review. This payment to
the accreditation organization is similar to the fees paid by
companies seeking approval of their product by Underwriters'
Laboratories, Inc.
Alternative Medicine
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Overview
Recently special interest groups and the media have focused on
the issue of access to" alternative medicine in the managed care
setting. Some of the alternative therapies of interest include
acupuncture, naturopathy, biofeedback, and massage therapy. A few
employers provide coverage for alternative medicine for their
employees, and some health plans provide coverage for" alternative
medicine. Organized medicine has just begun to look at the
benefits of certain" alternative treatments.
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CIGNA HealthCare Position
CIGNA HealthCare's Medical Technology Assessment Council
reviews new treatments and technologies to ensure that our members
have access to effective treatments. Requests for coverage of an"
alternative therapy are reviewed on a case-by-case basis by CIGNA
HealthCare's local medical directors to determine if the treatment
has been proven scientifically to be effective (e.g., supported by
peer review literature) and whether it is covered under the
member's benefit plan. If there is proven effectiveness and if the
local medical director has additional questions, he/she may
consult with an independent medical expert who provides a complete
objective assessment based on medical evidence.
Appeal and Grievance Procedure
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Overview
Opponents of managed care and the media have left the public
with the misimpression that a coverage decision is final, and
consumers and providers do not have the ability to appeal a
decision.
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CIGNA HealthCare Position
A CIGNA HealthCare HMO member can appeal a coverage decision by
accessing our multi-level appeal process which includes an
expedited procedure for emergency situations. CIGNA HealthCare
medical professionals — doctors and nurses — make coverage
determinations based upon a member's particular benefit plan, but
only a physician medical director can deny a request for coverage
of a procedure or service. Our members are notified in writing if
a request for a service or procedure is not granted and are
provided a description of how to access the appeal
process.
Clinical Trials
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Overview
As new drugs are developed for the treatment of a specific
illness or condition, they are tested for safety and
effectiveness. Health plan members sometimes request coverage for
medical treatment associated with a clinical trial. Clinical
trials are not without risks, and each trial needs to be evaluated
for potential benefits and risks.
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CIGNA HealthCare Position
CIGNA HealthCare reviews requests for coverage of medical
expenses associated with Phase 3 and 4 clinical trials on a
case-by-case basis.
Confidentiality
Protecting the confidentiality of your personal medical
information is as important to CIGNA HealthCare as it is to you
and your family.
CIGNA HealthCare will only release your confidential
information when necessary for the administration of your benefit
plan or to support CIGNA HealthCare programs or operations. For
example, we may disclose confidential information to your Plan
Administrator for the administration of your plan (such as an
audit of claim payments). Disclosure may also be made for
utilization management or to confirm the quality of the health
care and administrative services that are provided to you.
Additionally, we may disclose confidential information where
clinical data is required by medical professionals for your care
or is necessary for programs designed to improve your health. For
example, CIGNA HealthCare has developed care management programs
to help its participants manage some types of medical conditions,
such as asthma, lower back pain, or diabetes. We team up with
reputable expert organizations that specialize in administering
these programs. With our combined expertise, we are able to offer
such services as educational seminars and self-care tools to our
participants.
Whenever possible, we provide only data that do not contain
individually identifiable information. For individually
identifiable information, we have strict policies in place to
protect confidentiality. These policies apply to our own employees
and to all other individuals and organizations to whom
confidential information is disclosed. CIGNA HealthCare requires
these organizations to agree, in writing, that any individually
identifiable information will be used only for the purpose of
administering your benefit plan or providing health care services
and programs to our participants in accordance with all applicable
laws. A summary of the key points of our policy follows:
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Plan participant confidential information will be held in
confidence by all CIGNA HealthCare employees, non-employee
members of committees, contracted providers and any companies
acting on behalf of CIGNA HealthCare.
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Confidential information in any form will be handled in a
manner that is designed to protect the information from
unauthorized or inadvertent disclosure or release.
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Release of confidential information will be permitted only
when disclosure is required or allowed by law and necessary for
healthplan operations, administration of the benefit plan (such
as is required to audit CIGNA HealthCare's performance) or in
support of utilization management or programs designed to
improve the health of plan participants. When release of
confidential information is requested by an employer group or
benefit consultant for these purposes, every effort will be made
to accommodate the request without providing individually
identifiable information. Prior to the release of any
individually identifiable confidential information, the
recipient will be required to sign an agreement with CIGNA
HealthCare to keep the information confidential and to use it
only for the purposes stated above.
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When written enrollment forms are used, CIGNA HealthCare will
endeavor to obtain the plan participant's authorization to
release confidential information for healthplan operations,
administration of the benefit plan and other legitimate business
purposes. CIGNA HealthCare will make available to its customers
the appropriate authorization forms and materials explaining our
confidentiality policies and practices during each enrollment
period.
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CIGNA HealthCare will make every reasonable effort to ensure
that the information collected, maintained and acted upon is
accurate, complete, timely and relevant to CIGNA HealthCare's
specific business purposes.
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All employees will adhere to CIGNA HealthCare's standard data
security policy. In addition, every CIGNA HealthCare location at
which confidential information is maintained will have
procedures for labeling and storing confidential records.
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Plan participants may access their medical records by
submitting a written request. Any party seeking medical records
regarding another person will be required to submit a Consent
for Release of Medical Information form signed by the patient or
his/her parent/guardian.
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Employers and consultants will not be permitted to review
taped conversations between plan participants and Member
Services that have been taped in connection with an audit of our
telephone services until participant and provider identification
has been removed, unless otherwise permitted by state or federal
law.
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No employer or auditor will be permitted to view "live"
computer monitor screens containing individually identifiable
information during an audit of our telephone services.
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Prior to responding to a phone request for confidential
information, the caller will be asked to provide identifying
information to reduce the possibility of a disclosure of
confidential information to an unauthorized person.
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Whenever CIGNA HealthCare provides medical treatment in its
staff model healthplan, it will have additional policies and
procedures to protect confidential information.
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Requests for confidential information about any individual
plan participant regarding or relating to mental illness,
substance abuse, genetic testing results, HIV, or AIDS cannot be
released or re-released without a written consent from the
individual.
Continuity of Care
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Overview
Continuity of care concerns can be triggered by several
different events — i.e., a contract with a provider participating
in a network is terminated (either by the provider or by the
health plan) while a member is undergoing a course of treatment
from the provider, or a member's employer selects a different
health plan to provide coverage to its employees and a provider
that an employee is actively receiving treatment from is not in
the new network.
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CIGNA HealthCare Position
If a contract with a provider participating in a CIGNA
HealthCare network is terminated or an employer selects CIGNA
HealthCare as its new carrier while an employee is receiving care
from a non-participating provider, CIGNA HealthCare will work with
the member to assure that there is continuity of care. Assuring
continuity of care could be accomplished by allowing the member to
continue to receive treatment from the current provider or working
to effect the smooth transition of care to a participating
provider.
Direct Access to Specialists
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Overview
Managed care has reemphasized the importance of the primary
care physician (PCP). This development has been very threatening
to many medical specialists, and they have been seeking
legislation that would require health plans to allow members to
have direct access to their services (i.e., dermatologists,
ophthalmologists, etc.).
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CIGNA HealthCare Position
CIGNA HealthCare believes that the primary care physician is
the cornerstone of all care provided to our members. The primary
care physician, who is familiar with the patient and his/her
health history, is responsible for coordinating care for the
patient, including the provision of primary and preventive care
and referral to specialists when needed. The relationship CIGNA
HealthCare members establish with their PCPs facilitates better
use of specialty services. The PCP makes sure that the member is
seeing the appropriate specialist for his/her condition and
confers with the specialist to give details on the member's
condition and health history.
For members with complex health conditions, the role of the PCP
is essential. The PCP leads the team helping the member to manage
his/her multiple health conditions and treatment — often this
includes assuring proper access to specialty care and making sure
that all of the specialists are keeping one another informed.
Under certain circumstances when it is determined that the
ongoing needs of a member with chronic or multiple illnesses would
be most effectively met by a specialist, that specialist becomes
the primary care provider for that member (i.e., an AIDS patient
may use an infectious disease specialist as his/her PCP). This
decision would be made as part of our case management process,
which is an integral part of all CIGNA health plans.
Additionally, if a member would like to see out-of-network
specialists for increased out-of-pocket costs, CIGNA HealthCare
offers point-of-service (POS) plans (an HMO with an opt-out) or
preferred provider (PPO) plans.
Disclosure
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Overview
Disclosure of information to the consumer has surfaced as a key
issue in the public debate over managed care. There is a
misperception that health plans do not give their members basic
information about the plan such as: what is contained in the
benefit plan they have selected, how to access services, which
providers are in the network, what is the appeal and grievance
procedure, etc. Consumer advocates and others are interested in
requiring health plans to disclose financial information such as:
what percentage of each premium dollar goes to the delivery of
medical care versus administration of the plan, the specific
amount providers are compensated, etc.
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CIGNA HealthCare Position
CIGNA HealthCare believes that full information disclosure is
essential to member satisfaction and the delivery of quality care.
CIGNA HealthCare members receive a thorough description of their
benefit packages, including the following: exclusions and
limitations, the definition of emergency care, how to access
primary and specialty care, how to access care away from home,
out-of-network benefits, member rights and responsibilities, the
appeal and grievance procedure, a directory of participating
providers, and other important information.
Emergency Room
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Overview
Widespread reports of emergency room claim denials by HMOs have
led to calls for legislative solutions. The federal Emergency
Medical treatment and Active Labor Act (EMTALA) was enacted to
prevent hospitals from determining whether a patient could pay for
care before it was rendered. EMTALA requires hospitals and
emergency room physicians to screen and stabilize emergency room
patients regardless of whether the patient is in an emergency
situation. When an HMO member seeks treatment for a non-emergency
condition in the emergency room, he/she is responsible for the
cost of screening and any treatment rendered. As a result,
hospitals and emergency room physicians are often not being paid
for these services. They have seized this issue and are seeking
legislation that would guarantee payment for all treatment
provided in emergency rooms, regardless of the medical necessity
of the services. This proposal would remove the financial
disincentive for inappropriate use of the emergency room and would
interfere with the primary care physician's ability to provide
quality care to each of his/her patients by disrupting the
continuity of care. In effect, it would encourage people to use
the most expensive health care setting, the emergency room, as
their primary care physician.
Another issue is that emergency room claims are initially being
denied because hospitals and emergency room physicians disclose
only the final patient diagnosis on claim forms. When the
presenting symptoms are disclosed, the claims are often paid.
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CIGNA HealthCare Position
CIGNA HealthCare's goal is to provide quality, coordinated care
in the most appropriate setting. Emergencies should be treated in
the emergency room, and patients should get emergency care when
they need it — at the sudden and unexpected onset of a serious
injury or serious illness. Members do not have to get prior
authorization from their PCP before seeking treatment in an
emergency room in a situation in which a "prudent layperson" would
believe such emergency care is required. In addition, if the
member's primary care provider refers him/her to the emergency
room, the claim will be covered.
Non-emergency conditions should be treated by a member's PCP at
the PCP's office. CIGNA HealthCare encourages its members to seek
treatment for non-emergency conditions as soon as possible. CIGNA
HealthCare, by contract, requires its primary care physicians to
maintain 24-hour, 7-day-a-week telephone coverage and to provide
an appointment within 24 to 48 hours of a request, depending upon
the patient's condition.
New and Emerging Treatment (Experimental)
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Overview
HMO standards for coverage for new and emerging treatments have
become subject to increased scrutiny. The general public is under
the false impression that HMOs and managed care companies do not
provide coverage for new treatments, drugs, or devices — often
called experimental treatment — because they are expensive and
unproven. This issue has received a great deal of media attention
in relation to coverage for autologous bone marrow transplants
(ABMT) for the treatment of breast cancer as well as coverage for
clinical trials.
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CIGNA HealthCare Position
CIGNA HealthCare evaluates requests for coverage for new
treatments on a case-by-case basis. The CIGNA HealthCare coverage
review process uses internal and external sources — including its
Medical Technology Assessment Council, peer-reviewed medical
literature, and independent medical experts to assist its medical
directors in reaching coverage determinations.
CIGNA HealthCare opposes legislative mandates that would
require coverage for particular treatments or drugs because
medical science is not static, new treatments are constantly being
discovered, and changes are being made to existing treatments on a
regular basis. Government should not be involved in deciding what
is the best medical treatment for a particular health
condition.
Financial Incentives / Provider
Reimbursement
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Overview
The manner in which health plans reimburse providers is another
issue that is coming under increased public scrutiny. Providers
unhappy with the changes managed care has made in the way they are
paid have raised the issue. They assert that managed care payment
arrangements, particularly capitation, reward physicians for
providing less care.
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CIGNA HealthCare Position
CIGNA HealthCare opposes the use of financial incentives that
encourage physicians to deny care. CIGNA HealthCare uses several
different reimbursement options to compensate providers, which
include discounted fee-for-service, a salary and capitation.
Eligible physicians may receive additional payments based on their
performance on criteria that may include quality of care, quality
of service and appropriate use of medical services.
Formulary
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Overview
Some patient advocates and independent pharmacists contend that
drug formularies limit patient treatment options and can inhibit
therapy. In particular, media attention has focused on certain
drugs not being included on formularies. Patient advocacy groups
are seeking coverage for all FDA-approved drugs, regardless of
whether they are approved for the treatment for which they are
being prescribed. Legislative attacks are under way.
A study published in The American Journal of Managed
Care, a non-peer-reviewed journal (a.k.a. the Susan Horn
study), concluded that use of formularies increased use of health
care services, which resulted in lower quality and increased
costs. The study is flawed in several ways, the most important of
which is that it does not establish any baseline for results
(i.e., it does not look at drug costs and drug/medical utilization
patterns at the HMOs studied prior to the effective date of the
formularies).
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CIGNA HealthCare Position
CIGNA HealthCare uses a formulary
— a list of drugs covered by a member's benefit plan — to assure
quality and cost-effective drug therapy. Drugs on CIGNA
HealthCare's formulary are carefully selected by physicians and
pharmacists for their efficacy, and the formulary is reviewed and
updated regularly. This process allows our members to benefit on
an ongoing basis from advances in pharmaceutical science that can
dramatically improve the quality of people's lives. Hospitals have
used drug formularies in the same way for many years.
Health Plan Liability / Medical Director
Liability
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Overview
The issue of health plan liability for medical decisions first
surfaced in the debate over the Clinton health reform legislation.
It has resurfaced again in several state legislatures and at the
federal level. Critics of managed care are making the argument
that when a health plan denies coverage for a treatment or
procedure, it is making a medical decision because the health plan
is deciding what treatment it will cover and should be subject to
medical malpractice liability. (The underlying assumption is that
treatment will not be given unless the health plan will pay for
it.)
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CIGNA HealthCare Position
Health plan medical professionals make coverage determinations
based upon the terms of a member's particular benefit plan. Health
plan medical directors use utilization management guidelines to
assist in making such coverage determinations, but they are used
as just that — guidelines — and are not a substitute for a
clinician's judgment. The utilization management guidelines are a
set of optimal clinical practice benchmarks for a given treatment
with no complications and are based solely on sound clinical
practices.
At CIGNA HealthCare utilization management guidelines are
reviewed by each local health plan's quality committee, composed
of network physicians practicing in the area, and are modified to
reflect local practice. The guidelines are applied on a
case-by-case basis.
Mandated Benefits
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Overview
Mandated benefits require HMOs and insurers by law to provide
coverage for specific treatments and procedures and may set
durational limits on coverage (i.e., 10 visits, 48 hours of
hospitalization, etc.). These laws, typically enacted by state
legislatures, apply only to HMOs and insured plans and do not
apply to self-insured plans. Federal mandates, however, apply to
all employer provided plans, whether insured or self-insured. One
of the biggest concerns with mandated benefits is that they
increase the cost of health care coverage. Some recent examples of
mandated benefits include coverage for diabetic supplies,
equipment and education; prostate screening antigen (PSA) testing
for prostate cancer; bone densitometry for osteoporosis; breast
reconstructive surgery following a mastectomy; and mastectomy
length-of-stay requirements.
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CIGNA HealthCare Position
CIGNA HealthCare is opposed to the government determining
specific benefits to be included in HMO and insurance contracts.
CIGNA HealthCare believes that the marketplace should determine
what benefits should be offered by HMOs and insurers.
Mandatory Point-of-Service
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Overview
Legislative mandates that would require all HMOs to offer a
point-of-service plan, an HMO with an opt-out, have been
introduced in several states and have been enacted in several
others. Legislators are attempting to guarantee that consumers are
offered a health care coverage option other than a traditional
HMO.
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CIGNA HealthCare Position
CIGNA HealthCare opposes legislative mandates that would
require all HMOs to have an out-of-network benefit. This mandate
would increase costs for employers and members and would eliminate
traditional HMOs as a product offering in the marketplace.
Point-of-service plans are already an option widely available in
the marketplace.
Mental Health Parity
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Overview
In 1996 mental health advocates were successful in the passage
of federal legislation that requires employers who provide mental
health coverage to apply the same annual and lifetime dollar
limits to the mental health benefits as are applied to benefits
for physical illness. (This requirement is effective 1/1/98.)
Mental health advocates are now seeking state legislative mandates
that would require mental health coverage be provided in all
health plans at the same level of benefits as physical illness.
Some of the state proposals specify certain conditions, such as
biologically based mental illnesses, while others would require
all mental health conditions be treated the same as physical
illnesses.
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CIGNA HealthCare Position
CIGNA HealthCare does not support government mandating
benefits; however, we do support appropriate care and treatment
for mental illness.
Minority Providers / Essential Community
Provider
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Overview
Minority providers, concerned about being excluded from health
plan provider panels, are seeking legislative mandates that would
require health plans to contract with them. These proposals are
often called "essential community provider." The stated goal of
the proposals is to protect the existing health care
infrastructure in the inner city, rural areas and other medically
underserved communities and are touted as preventing racially
discriminatory practices in the selection of providers.
The concerns of minority providers have grown as more health
plans have entered the Medicare Risk market and as states have
turned to managed care systems for their Medicaid programs because
health plans, responding to pressures from employers and
consumers, contract with board-certified providers only.
Historically, minority providers have not applied for board
certification.
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CIGNA HealthCare Position
CIGNA HealthCare works to ensure that providers in its network
reflect the demographics of the provider community and the member
population.
Off-Label Drug Use
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Overview
Physicians often prescribe drugs for "off-label"use — the use
of an FDA-approved drug for treatment of a condition for which it
has not received FDA approval. In certain instances this practice
is considered to be experimental.
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CIGNA HealthCare Position
CIGNA HealthCare does not prohibit off-label use of approved
medications, but use of certain drugs does require
preauthorization. In those cases requests for coverage for
off-label drug use are reviewed on a case-by-case
basis.
Physician-Hospital Organizations
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Overview
Physician-Hospital Organizations (PHOs), also called
Provider-Sponsored Organizations (PSOs), are managed care delivery
systems formed by physicians and hospitals or health systems to
compete with HMOs and other managed care plans. PHOs seek
exemptions from federal antitrust standards as well as state and
federal solvency requirements and other consumer protection
standards which are imposed on HMOs and insurers. As part of the
last year's Balanced Budget Act, PHOs were successful in their
attempt to get special status to participate in the Medicare Risk
program allowing them, for example, to meet less rigorous
financial standards.
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CIGNA HealthCare Position
CIGNA HealthCare believes that there should be a level playing
field for all managed care players. All competitors should have to
meet the same types of regulatory requirements.
Physician-Patient Communication
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Overview
Health plan restrictions on physician-patient communication,
so-called "gag clauses," have been prohibited in most states.
Several anti-gag clause provisions are currently pending before
Congress.
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CIGNA HealthCare Position
CIGNA HealthCare has never imposed restrictions on
physician-patient communication. CIGNA HealthCare encourages its
physicians and their patients to freely and openly discuss the
treatments and procedures best suited for an illness or condition,
including treatment that is not covered in a member's benefit
plan.
Specialists as PCPs
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Overview
Specialists, concerned about managed care's emphasis on primary
and preventive care and having been unsuccessful at seeking direct
access legislation, are seeking legislation that would allow them
to be primary care providers.
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CIGNA HealthCare Position
Managed care emphasizes the importance of the primary care
physician who is specially trained for this role in residency,
just like a surgeon is trained to perform surgery. Most
specialists do not meet the training requirements to be primary
care providers.
For members with complex health conditions, the role of the
primary care physician is essential. The primary care physician
leads the team helping the member to manage his/her multiple
health conditions and treatment — often this includes assuring
proper access to specialty care and making sure that all of the
specialists are keeping one another informed.
Under certain circumstances when it is determined that the
ongoing needs of a member with chronic or multiple illnesses would
be most effectively met by a specialist, that specialist becomes
the primary care provider for that member (i.e., an AIDS patient
may use an infectious disease specialist as his/her primary care
physician). This decision would be made as a part of our case
management process, which is an integral part of all CIGNA health
plans.
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