[Congressional Record Volume 140, Number 35 (Thursday, March 24, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: March 24, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                            THANKS TO AETNA

                                 ______


                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Thursday, March 24, 1994

  Mr. STARK. Mr. Speaker, several months ago, I complained in the 
Congressional Record about two cases in my congressional area where 
seniors had been enrolled in a Medicare HMO arrangement, but the 
enrolling HMO--in this case Aetna--could not serve them. In essence, 
the two women--one suffering from severe mobility problems and the 
other suffering from dementia in a nursing home--were separated from 
the doctors who had been serving them without being able to access 
Aetna's HMO doctors.
  I want to report that Aetna's management has carefully and fully 
investigated the two cases and has taken important steps to right the 
two cases and ensure that it does not happen to others. The facts as 
presented to me in the two cases by a local community health center 
were not fully accurate, for which I apologize. Nevertheless, in 
reviewing what went wrong. Aetna has found ways to make sure that this 
kind of problem is more quickly detected and rectified in the future.
  If any Member has a constituent who, in confusion or through 
inadvertence, is enrolled in an Aetna plan in such a way to impact on 
their medical treatment, I urge you to contact Aetna. Their management 
has shown a willingness to walk a second mile to help resolve this kind 
of often complex and tragic case.
  Following is Aetna's letter and description of corrective steps. I 
hope other HMO contractors around the Nation will do as well.

                                                        Aetna,

                                     Hartford, CT, March 15, 1994.
       This letter represents the follow-up I promised you when we 
     discussed the problems raised by the Over 60 Health Center in 
     Berkeley, California (in its two letters to Chairman Stark).
       As you will recall the problems focused on the enrollment 
     of two individuals into Aetna's ``Senior Choice'' program. In 
     the first case the individual was reportedly solicited while 
     a nursing home resident and in the second case there was some 
     confusion as to program terms and conditions.
       Sometimes no matter how hard we try, something unacceptable 
     happens. For example, while it is clearly not the policy of 
     Aetna to pursue the enrollment of nursing home residents into 
     Senior Choice, in the first case at hand the individual was 
     in a nursing home at the time of enrollment. The whole story 
     reveals, however: that no Aetna solicitation or marketing 
     took place at the nursing home (which would have been against 
     Aetna policy); the actual enrollment was effected by the 
     granddaughter and not the member herself; and the application 
     submitted to Aetna clearly stated the individual was not a 
     resident in a nursing home.
       Thus in this first case, contrary to the implications/
     statements in the Congressional Record:
       Aetna did not sign this individual up at a nursing home.
       Aetna did not make a sales presentation at the nursing 
     home.
       The granddaughter (not the niece) enrolled the grandmother.
       The application (signed by the granddaughter) said the 
     applicant did not reside in a nursing home.
       And in the second case, contrary to the implications in the 
     Congressional Record:
       The member applied to Senior Choice in response to direct 
     mail advertising.
       Subsequently the member was hospitalized and treated by non 
     Senior Choice Providers.
       When contacted by Aetna Health Plans, the member did not 
     recall enrolling into the Plan.
       From our perspective these cases do not in any way ``fit'' 
     the characterizations of Aetna as printed in the 
     Congressional Record. They do however point out the utility 
     of being cautious, even to the point of being repetitive, to 
     make sure senior citizens know absolutely, positively the 
     terms, conditions and consequences of enrolling in a Medicare 
     managed care plan (before, during and after enrollment).
       While the harsh words in the Record are not deserved, our 
     review of the two cases referenced in the Record has helped 
     us formulate changes in our procedures with respect to the 
     Senior Choice Program. These changes are designed to go the 
     ``next step'' to minimize any potential shortcomings in our 
     procedures. Our overall Corrective Action Plan will:
       Solidify our education/marketing practices as they relate 
     to communicating to potential and new members just what it 
     means to sign up for a network-based product under Medicare.
       Enhance our ability to identify and follow-up on continuing 
     care issues and circumstances involving members prior to or 
     as they enroll;
       Enhance communications among departments to improve our 
     ability to arrange for Medicare members to receive the 
     services they need;
       Improve communications with our Medical Groups/IPAs to make 
     sure they understand their obligation to provide or arrange 
     for care of institutionalized members.
       The ``bottomline'' here is as follows:
       Appropriate steps have been taken to disenroll both Senior 
     Choice Members in these two cases and to re-enter them into 
     ``regular'' Medicare.
       All provider bills for Medicare covered services have been/
     will be paid for both individuals during the time of Aetna 
     coverage.
       All appropriate reimbursement to the Over 60 Health Center 
     in connection with services to these beneficiaries will be 
     made.
       A series of corrective steps is being put in place to 
     provide additional ``safety net'' procedural protections 
     against repeat situations.
       We are actively looking at our records to see if there are 
     other cases that deserve our attention. You can be sure that 
     if I uncover other situations, they will be handled with all 
     due appropriate care. (If any cases come to your attention, 
     please let me know.)
       At Aetna we are quite mindful of the vulnerable status of 
     our senior citizens and of our responsibility to make sure 
     our Senior Choice Program is fully understood. We are not the 
     kind of company as described in the 2/1/94 Congressional 
     Record. We are rather the ``White Hats'' of the industry (as 
     so identified by Chairman Stark at a Long Term Care hearing a 
     while back) and by our conduct in the cases at hand, I think 
     we have continued to earn this characterization.
       We encourage you to use this letter to set the record 
     (Record) straight.
       We pledge to continue to serve our Senior Choice members 
     with the highest quality of care. I look forward to hearing 
     from you, and hopefully seeing some kind words about Aetna in 
     the Record.
           Very truly yours,
                                              Jonathan M. Topodas,
     Vice President and Counsel.

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