DRASTICALLY thin provider networks on Obamacare Exchange plans
[Update] I've added some revisions, links and updates.
Thanks for adding me, Lambert
The past couple of days I’ve heard constant talk of the deals people are getting on the Obamacare Exchanges, (when the servers are up, of course). $120/month premiums, $500 or less deductibles. All of this sounds like a great triumph of liberal social policy. And if that were the whole story, I would definitely agree.
However, buried in the slimy underbelly of all of it is the new paradigm shift that has been defacto, if not purposefully engineered by the law. That is, the plans on the Exchanges offer **drastically** thin provider networks. I know Lambert has talked about this, but I am not sure that he understood how bad it really is. I know I didn’t, and I have a degree in cynicism (aka Political Science). People may see this in the abstract and think, oh well, a few doctors will be left out. But what is happening nationwide and in my Seattle area is that the highest quality and most major research, teaching and cancer hospitals, as well as a large portion of the top doctors in areas are being left out of the in-network provider list in Exchange plans. As I’ve said, this is a paradigm shift in how health insurance works in our country. People think they are getting the same kinds of plans on the Exchanges that they’ve always gotten through work or the individual markets. They. Are. Not.
[Update]Even Kevin Drum is saying this is going to be a festering sore. But he doesn't get how huge of a deal it really it is, especially how it DOES revive the Republican boogieman of rationed care. The provider networks for Exchange customers are thin. The thinning is done by eliminating research, teaching, and cancer hospitals and doctors of the same from the list, the orgs that provide cutting edge care. In addition, companies are dumping their employees onto these networks, so more people are going to be forced to access fewer and second tier networks of doctors and hospitals. Isn't this rationing of care? If you have difficulty picturing what will happen, Google Medicare and Medicaid doctor access problems. In addition, the thin provider networks coupled with the fact that out of pocket maximums for out of network providers are not CAPPED by the law means that effectively we are no longer financially protected by our insurance for catastrophe if we need to see an out of network provider, say, for cancer, for organ transplant, you know, the events that this law was supposed to save us financially from.
To bring the issue into sharp focus, here is a list of MOST of the hospitals in the Seattle area that are OUTSIDE OF the NETWORK on the Exchange plans offered by Premera, our only Washington Blue Cross affiliate:
- Swedish Hospital (major Seattle Hospital with branches all over town and in suburbia)
- University of Washington Medical Center (Our teaching hospital)
- Providence Hospital (another major hospital)
- Harborview Medical Center (Major trauma center affiliated with University of Washington. People all over the state are flown to this hospital for trauma treatment.)
- Seattle Cancer Care Alliance (our Fred Hutchinson Cancer Research Center hospital).
- Veterans Medical Center
I do not have a grasp of how many doctors in private practice have been dis-included, but I do know that no doctors at Polyclinic are included either. Polyclinic is a large Seattle area clinic, known for its rock-star doctors.
I’m finding a similar situation from Bridgespan, which is the Exchange plan offered by
Regence (our Washington Blue Shield affiliate) Cambria. However, I cannot reach a person on the phone to confirm. When I called the number on the Bridgespan web site, the person I reached had no idea why I called him. He forwarded me to “Seattle Customer Service,” which turned out to be one individual's voicemail. Figuring if she got back with me at all, it would be days, I gave up. [Update] Bridgespan does appear to offer Harborview Hospital as an option, but the other hospitals are excluded.
At first, I thought, well, if a person is desperate they can just go to an in-area, but out-of-network provider. However, the new plans have 2 tiers of deductibles/coinsurance and out of pocket maximums, one for in-network and one for out-of-network providers. Out-of-network deductibles and copays on these plans are typically at least twice as high as their in-network counterparts, and they are not subject to cost sharing subsidies. In addition – and this is the greatest travesty – the law appears not to have regulated spending caps for out-of-network providers. Thus, the plans on Premera Blue Cross have an UNLIMITED out-of-pocket maximum for out-of-network providers. (Link to the Premera silver plan)
Translated this means if you have emergency out-of-your-very-thin-network care needs, your cost burden is apparently UNLIMITED. [Update] The law does have a provision that insurers cannot charge more for emergency services using out-of-very-thin-network providers. However, they did nothing to prevent hospitals from balance billing, a policy that is legal in most states when you use out-of-network providers. And hospitals routinely do this. Remember that insurance companies pay very low reimbursements for care, so balance billing effectively makes your charge for an out-of-network ER unlimited. And assuming that you can afford to pay an unlimited cost, none of what you paid applies to your deductible, coinsurance or out of pocket maximum once you get to your home network. This all flies in the face of Pelosi's justification that Obamacare would stop people from contracting medical emergencies they can’t pay for. And of course, Obamacare cut funding to subsidize emergency care for the poor.
Notes about my links in the last paragraph:
The balanced billing link is snarky at times and from an MD's perspective. But it provides a descriptive picture of why hospitals probably won't give this policy up any time soon.
My Kaiser link that summarizes the states that allow balanced billing for out of network providers mentions MANAGED CARE in its title. Don't confuse MANAGED CARE with HMO. Managed care includes HMO's AND Preferred Provider Organizations (PPO's)).
One of the issues this law was sold on was that it would eliminate medical bankruptcy for extreme care needs. However, in the Seattle area, none of the in-network Premera plans (and Bridgespan pending) have in-network hospitals offering bone marrow transplants. And as far as I can tell, only one of the hospitals offers organ transplants, but I haven’t gotten to researching if the doctors who do those transplants at that hospital are in-network providers. In-network providers exist for basic cancer or heart care treatment, however with the especially thin provider network, this care will likely be defacto rationed, as not enough providers are available to offer the care. I could go on, but you can fill in the blanks, I'm sure. People who need accelerated care may have no choice but to go to an out-of-very-thin-network hospital or doctor. If they do, because of either uncapped out of pocket maximums, balance billing for out of network providers or both issues, I believe their cost exposure will be nearly as unlimited as if they had no insurance at all.
Also, as we all know, more and more companies are dumping people onto the Exchanges. As the subscriber list on the Exchanges grow, because of the radically thin provider networks, the wait times will also grow even longer. The Republican boogie-man of rationed care may very well become real -- and for an increasing number of people, not just we poor sops who have been on the individual market or without insurance all along.
“Progressives” should be screaming. This should be front page news. The equivalent of Code Pink should be camping on the DC doorsteps and at every capitol building in our country. But the brilliance of this horrifying aspect of the law is that because the “progressive” grass roots love Obama or are otherwise living in denial, they remain silent. Worse yet, they sometimes cheerlead this policy travesty, saying it's "cost-cutting". It makes insurance more "affordable". For the last time, health insurance is NOT health CARE. Are they so naive that they don't realize that this change is the beginning of the destruction of the individual market as a place to get much care at all?
[Update]One of the reasons my hair is on fire is I hope it somehow makes the few employers who have shown some modicom(sp) of conscience rethink dumping their employees onto the Exchanges. When they do, they are not providing traditional insurance. They are providing very skinny insurance plans. Trader Joe's, I'm looking at you.
[Update]I noticed someone at Daily Kos copied my post into comments. I was flattered until I saw others trashing it, then I chuckled. The denial is strong, especially when we've been so effectively sold a bill of goods. I invite people to tell me where I'm wrong about this. But I'll warn you. Research and analytical skills are my strong suits.
But off my soap box. If you have decent coverage and are thinking of switching to a ‘cheaper’ Exchange plan, please do some detailed research into the provider network first. Don’t just look at premiums and in-network copays. And please tell your friends and family to do the same.
And I invite you to research the travesties of your local Exchange provider networks as I have, and post them in the comments. Also, please write your newspaper, your Congressperson, or on your blog and share the same with them.
Thanks for your ear. Sorry in advance for my typos ;-).