WASHINGTON -- A long-running dispute between doctors and insurance companies boiled over yesterday as the American Medical Association joined a liberal Democratic senator in proposing legislation to regulate the techniques used by insurers to control health costs.
Dr. Lonnie R. Bristow, the chairman of the medical association, said doctors and patients both suffered when insurers denied payment for medically necessary services and excluded competent doctors from their health care networks.
He and Sen. Paul Wellstone, the Minnesota Democrat who is sponsoring the legislation, lamented the domination of medicine by large corporations that they said were more concerned about profits than the welfare of patients.
Under their proposal, health plans would have to disclose the standards they used to select and exclude doctors from their networks, and doctors would have a right to appeal their exclusion. The bill would not allow a doctor to be dismissed from a health care network "without cause."
At a news conference yesterday, Dr. Bristow said insurers often refused to sign contracts with doctors who provided high-quality care but performed many expensive procedures. Under the legislative proposal, known as the Patient Protection Act, nurses or clerks could not deny payment for a medical service; such decisions could be made only by doctors specializing in the same field as the doctor who performed the service in question.
Any health plan that limited access to doctors would have to give patients an opportunity to see doctors outside its own network.
Insurers and health maintenance organizations denounced the new proposal, saying it was intended to protect doctors, not patients.
Karen M. Ignagni, president of the Group Health Association of America, a trade group for HMO's, said the decision about whether to include a doctor in a health plan was based on many factors that could not be disclosed for competitive reasons.
"It's not at all scientific," she said. "There are qualitative factors here. Our plans analyze physician practice patterns, the quality of care and patients' needs. But this is proprietary information. If you're an HMO, you don't want to disclose your selection criteria to your competitors. Is Congress now going to set the criteria whereby HMO's build their physician networks?"
Senator Wellstone supports having the government be the main payer for health care. Some doctors have concluded that such a proposal, known as a single-payer plan, is desirable because it would protect the clinical autonomy of doctors, by eliminating detailed supervision and review of their decisions.
"We are in danger of losing our professional autonomy to colossal HMO's and mega-corporations," said Dr. Quentin D. Young of Chicago, national coordinator of Physicians for a National Health Program, which has 6,000 doctors as members.
John M. Gibbons, a spokesman for the Alliance for Managed Competition, which represents five big insurance companies, said he was surprised at the tone of Dr. Bristow's comments. "It was much more strident than we had anticipated," he said.
"The AMA doesn't represent all physicians," Mr. Gibbons said. "Many physicians are quite happy with their relationship with managed care companies. They feel the companies are providing high-quality care."
The alliance represents Aetna Life and Casualty, Cigna, the Metropolitan Life Insurance Co., the Prudential Insurance Company of America and the Travelers Corp. Barbara B. Hill, who supervises health policy at Prudential, said the doctors were trying to "hold onto the status quo with local physician control," while managed care companies wanted to set national criteria and guidelines.