Aetna, Inc., one of the nation’s largest health insurers, agreed to pay physicians an estimated $100 million to settle claims against it in a national class-action lawsuit that alleges the company interfered with recommended treatment for patients, and denied referrals to specialists. The announcement was made in a press conference held on May 22 by Aetna’s chairman and CEO, Dr. John W. Rowe. AMA president Dr. Donald J. Palmisano was also in attendance to show his support for the decision and stated that “The AMA anticipates other health plans will recognize the progressive nature of today’s agreement if they are serious about restoring confidence in our health care system and repairing badly damaged relationships with physicians.” Aetna is but one of several health insurers named in the lawsuit that includes Anthem, Inc., Cigna Corp., Humana, Inc., PacificCare Health Systems, Inc., United Health Group, Inc., and Wellpoint Health Networks.
Under the settlement, which still must be approved by the U.S. District Court in Miami, Aetna will pay an additional $50 million in legal fees, $300 million to improve business practices, and $20 million to establish a foundation for the improvement of health care. Aetna will release to the public its policies and procedures regarding medical treatment decisions and payment methodology; show clearly delineated appeals mechanisms for external review; and form an independent foundation to deal with critical health care issues and also establish a National Advisory Committee of Practicing Physicians to provide advice to Aetna on issues of concern to physicians. Most significantly for physicians, Aetna agreed in the settlement to accept general treatment guidelines developed by the American Medical Association that bases decision-making on a physician’s prudent clinical judgment. Aetna previously approved treatment on what it thought was the least costly approach.
The lawsuit is one of the largest ever in the health care industry, and includes most of the estimated 700,000 practicing physicians in the U.S. Each physician will share the $100 million, which is equivalent to about $150 each. The remaining health insurers named in the lawsuit have stated they will continue to vigorously defend against the suits still pending before the U.S. District Court.