A federal judge has ordered Aetna Health Plans of New York to turn over internal records in a potentially far-reaching case challenging the HMO company's use of capitation.
U.S. District Judge Denis R. Hurley in Hauppauge, N.Y., ruled that Aetna must provide certain records and other materials to the plaintiff's attorney. He did so as he rejected Aetna's request for an early ruling in its favor that would have ended the lawsuit.
The data include information supplied to Aetna's quality-management and utilization committees in New York and six other markets where it has capitation in place. There's also information on the de-selection of network physicians who were deemed "cost outliers" because they gave too much care to patients, said plaintiff's attorney Whitney North Seymour Jr., a partner with New York-based Brown & Wood.
"Our argument was that it will show whether there was a higher level of patient-care problems in the markets where there is capitation in effect than in the markets that have fee-for-service," Seymour said.
The motion is the latest in a case brought by Mara Maltz, the mother of two teen-agers with Crohn's disease, a chronic illness involving inflammation of the gastro-intestinal tract. Last December, Maltz filed suit alleging that Aetna breached its fiduciary duty to beneficiaries by threatening to terminate physicians who refused to switch to a capitation payment system. Her children's physicians were among those affected by the plan's attempt to move to capitation (Jan. 8, p. 22).
Aetna Life and Casualty Co., the parent of Aetna Health Plans, announced plans to acquire U.S. Healthcare this summer. The company has not determined how it will respond to the judge's order. "We're examining our options," said Walt Cherniak, a spokesman for Aetna U.S. Healthcare, Aetna Life and Casualty's healthcare business arm.
The suit by Maltz contends Aetna violated ERISA, the Employee Retirement Income Security Act, the federal law that protects the interests of participants in self-insured and union-sponsored benefit plans.
Earlier this year, though, the court refused to stop Aetna from dropping doctors who decline to accept capitated rates (June 3, p. 4).
"The case is still going on," Cherniak said. "We're still confident we're going to win."