The court will decide whether or not Blue Cross/Blue Shield honored its contractual agreements with patients and providers.

BY JENNIFER DAW HOLLOWAY
Monitor staff
Print version: page 24

The case the Virginia Academy of Clinical Psychologists (VACP) filed against Care First (formerly Blue Cross/Blue Shield of the National Capital Area) and its mental health subcontractor (formerly Value Options) to hold the companies accountable for essentially putting profits ahead of patients--by not providing the services it promised to consumers or providers--is scheduled for trial on April 7. After many delays, several judges and a couple of pretrial hearings, the moment this group of Virginia psychologists and consumers has been waiting for is here (see The long road to trial for case chronology).

The case began when the plaintiffs--VACP, five psychologists (Elizabeth Hauck, PhD, John Gualtieri, PhD, Glen Chilstrom, PhD, Victor Elion, PhD, and Sally Horwatt, PhD) and two consumers--alleged that Care First's 30-percent unilateral cut of payment rates constituted a breach of the contract with participating providers, which required mutual consent of the parties for a rate reduction. Further, the plaintiffs say they were told that if they did not consent to the reduction, they would be considered to have "resigned" from the panel.

In addition, the plaintiffs also allege that the defendants imposed hidden limitations on the number of psychotherapy sessions advertised and promised to consumers who subscribed to the plan. The defendants allegedly switched patients from HMO coverage to more expensive PPO coverage for outpatient psychotherapy long before patients reached the maximum number of psychotherapy sessions covered under the HMO plan.

According to APA Executive Director for Professional Practice Russ Newman, PhD, JD, "The crux of this case is whether managed-care companies can operate as just another 'business,' putting their financial bottom line first and patients second. We think health care is more than just a collection of business contracts," Newman says. "To the extent that contracts with health professionals and consumers are involved, managed-care companies shouldn't be able to arbitrarily decide whether or not they want to honor their contractual agreements," he adds.

Though it's been slow going since the beginning, the plaintiffs--with support from APA and financial support from many psychologists around the country--hope that this case will prove that managed care must be held accountable, and that the defendants must live up to their contractual promises, says Shirley Higuchi, JD, assistant executive director for legal and regulatory affairs in APA's Practice Directorate.

Adds Higuchi, "We're up against a managed-care giant--they're well-funded and like most health-care advocacy organizations, we don't have the resources they have. But we are committed to making the health-care system better for patients and providers."