There's good news and bad in the battle to make managed care accountable to patients and providers, specifically in the case of the Virginia Academy of Clinical Psychologists (VACP) against Blue Cross/Blue Shield of the National Capital Area (now Care First), Value Options and related companies. A June 26 summary judgment ruling cleared the way for two out of the case's three core claims to proceed to trial. Plaintiffs will get their day in court over contract claims that the defendants did not make good on the services they had promised to deliver to consumers or on the reimbursement they had promised to the psychologists. The judge, however, dismissed plaintiffs' claims that the defendants had intentionally misled them.
The case began four years ago when the plaintiffs--VACP, six psychologists and two consumers--alleged that the defendants' 30 percent cut of payment rates forced psychologists off the managed-care panel. That action, they claim, left many patients unable to get services, even as the company advertised it had a large, stable panel of mental health professionals. Plaintiffs also alleged that the defendants imposed hidden limitations to ensure that patients did not get the number of HMO sessions that Blue Cross advertised.
"To me, what the case is about is the impact of the fee changes on patients," says plaintiff Elizabeth Hauck, PhD. "But we believe that the surviving contract claims are also very important--we seek a ruling that says Blue Cross must honor its promises to patients about the cost and availability of care, and its promises to psychologists about adequate compensation."
The court's decision to look only at contractual issues "doesn't hold managed care sufficiently accountable," says Russ Newman, PhD, JD, APA's executive director for practice. "When managed-care companies make promises to put patient needs first, we argue they've misled subscribers," he says. "Their priorities are profits, finances, cost and economics--not patients."
But this isn't the end of the road, Newman says. The claims over the managed-care contracts with psychologists and consumers will go to trial soon and the plaintiffs, with the support of APA, will most likely pursue an appeal to address the fraud claims. "The mills of justice grind very fine--and very slow," says Sally Horwatt, PhD, another plaintiff. But she says VACP and the other plaintiffs are in it for the long haul. "I think that time is working against managed care's high-handed tactics."
At Monitor press time, the trial date was set for Jan. 13.