I have to come up with an analogy for the Great Medical Insurance problem here in the US. The Rebels vs. The Empire? Robin Hood vs. The Sheriff of Nottingham? David vs. Goliath? None of these is just right, but they each contain elements of the issue: a giant, controlling source of pain and trouble being fought by the little guy (or woman - see below). It's a matter of time before we see the Erin Brokovitch movie about the insurance industry.

What a delight it was, then, to read this month's SOAPM newsletter (past issues are available at the AAP as well as at PCC, as we sponsor the newsletter). First, I read Dr. Francis' piece reminding pediatricians to go to hmosettlements.com to participate and keep an eye on the settlements with Aetna, Healthnet, Wellpoint, Humana, and Cigna. Just go read the entire site.

Even better was the description, from Dr. Stoller, of how she discovered Aetna was in violation of their settlement terms and, through just a little work, was able to recover a significant amount of income relating to -25 modifiers as well as mis-processed "out-of-network" claims (that were really in-network). As she says, "FIGHT BACK!"

Then, I got the email:

horizon class-action lawsuit settled

Good work. My favorite part of the email reads as follows:

This latest national class-action settlement is one in a series of actions against major healthcare insurers and another milestone in the check against widespread and chronic abuses against physicians. These class-action lawsuits have resulted in significant reforms in the health insurance industry.

The settlement consideration includes a guaranteed cash payment of over $128 million to class members. In addition, the settling defendants have agreed to implement important business practice changes that will bring the estimated value of the entire settlement consideration to well over $1 billion.

Perhaps an Austin Powers analogy would work? "One Billion Dollars."

It gets better, though:

The agreement follows similar settlements with other major managed care companies, with the exception of United Healthcare, who continues to litigate against physicians rather than making the kinds of positive practice changes other insurers have agreed to make.

Indeed, United Healthcare has repeatedly refused to address the significant concerns raised by representatives of the more than 400,000 physicians nationwide who care for United Healthcare's members. According to MSNJ CEO & Executive Director, Michael T. Kornett: United Healthcare simply has not raised its standards to what has become the industry standard in healthcare. United Healthcare has systematically engaged in practices of coercion and intimidation that are akin to the actions of a school-yard bully. When all the other major national healthcare insurers agree to conduct business with their physician/providers in a more transparent and fair manner, it is difficult to understand why United Healthcare refuses to operate on a more level playing field.

Wow. Although I assume it actually isn't difficult for anyone to understand why United behaves this way, kudos to the Medical Society of New Jersey for stepping up.