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Obamacare Clusterfuck: Hospital sues its state commissioner over not being included on Exchange plans.

Dromaius's picture

Left off many networks, Seattle Children’s sues

Seattle Children’s filed suit Friday over the state Office of the Insurance Commissioner’s “failure to ensure adequate network coverage” in several health plans being sold through the state’s new online insurance marketplace, called Washington Healthplanfinder. ... Families that enroll in those plans could face significantly higher cost-sharing amounts they have to pay if they seek care at Children’s rather than at in-network providers.

Exactly as I've been saying.

Children’s officials say they are worried that families may sign up for coverage without realizing that the pediatric specialty hospital is not in most of the plans’ networks.

Ayep. People may sign up for coverage, not realizing that most of their area hospitals are not included in their provider lists. It is irresponsible that the Insurance Commissioner doesn't make this apparent for people, given that it is a NEW PARADIGM.

The lawsuit underscores a concern that has emerged in Washington state and elsewhere that many health plans sold through the exchanges may have “narrow networks” of providers compared with those offered in commercial health-insurance products.
Children’s officials say the hospital’s exclusion from the exchange plans represents a significant change for the pediatric hospital, which has typically been included in most health plans in the state’s commercial market. “The notion that a major insurance plan is going to exclude us from their network is truly precedent-setting and represents a new level of degradation in children’s access to care,” said Dr. Sandy Melzer, the hospital’s senior vice president and chief strategy officer.

Dr. Melzer, you are channeling me. You can say the same about all of the rest of the hospitals that have been dis-included from Exchange plans nation-wide. Children's Hospital does not just serve Seattle. It serves the entire Northwest. It does child bone marrow transplants. It treats the bubble boys and girls. I can't find the link now, but I read last night that half of its patients are Medicaid recipients. This is not about being a fat cat.

Insurers say they are trying to balance the need to offer adequate networks of providers with market demand for affordable health insurance. “Affordability is still the single most important concern,” said J. Mario Molina, president and CEO of Molina Healthcare, which is offering exchange health plans in several states, including Washington.

Well if it's about affordability, then why don't you actually insure people, Mr. Molina? (See all of my posts about the dangers of limited provider networks.) Plans with limited provider networks effectively do not cover catastrophe or severe illness in any way that you can count on. Covering catastrophe is what insurance is about.

[Insurance Commissioner's Office Response:] “We are reviewing Children’s petition to see what lies at the heart of their concerns and will see how it gets resolved through the legal process,” she said.

[Headslap] This is the same kind of tripe I get when I write to our commissioner. Insurance Commissioner = PR Apparatus for the ACA.

I am hoping that this case brings the issue to the forefront in a way that little me with my hair on fire will never be able to. I fear, though, that Children's will get what they want and walk off, leaving people thinking that everyone is okay now.

I would like to file a lawsuit on behalf of my state citizens to require that the Insurance Commissioner rate these plans based on provider network, to inform the public in a real way about what they are buying. I have no money for this, but if you have ideas about someone who would help me in a pro bono way, let me know.

Again, this is not about fixing ONLY my state. It is about raising awareness nationwide, using an example from my state.

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Comments

jo6pac's picture
Submitted by jo6pac on

I hope more do this and thanks teresa for the update. I agree with lambert but I like it when the rent fight it out among themselves. Then again the losers are normally us on Main Street once they've decide who lives and who dies in the corp. world or who has the most puppets in congress to outlaw the competitors.

Submitted by hipparchia on

I can't find the link now, but I read last night that half of its patients are Medicaid recipients.

i did find this: http://seattletimes.com/html/localnews/2002665026_childrenshospital05m.html

some excerpts:

Dr. Tom Hansen, the new president and CEO at Children's Hospital, said that loss of Medicaid funds would have repercussions beyond the hospital's neediest patients. More than 40 percent of its patients receive some kind of state-federal assistance, he said.

and

Seattle Children's may represent only one hospital in a four-state area but it handles 50 percent of the sickest kids, he [Peters D. Wilson, vice president for public policy at the National Association of Children's Hospitals] said.

and

Children's hospitals nationally have a high percentage of Medicaid patients. They also are responsible for more than half of the specialized pediatric heart surgeries, organ transplants and child cancer care.

i don't know if that's what you were looking for, but it's exactly the kind of information i've been looking for. thank you for posting about this.

Submitted by hipparchia on

ohio: http://www.ohiochildrenshospitals.org/advocacy-and-issues/medicaid

When compared to general hospitals (which average about 12 percent Medicaid caseload), Ohio’s children’s hospitals have the highest share of Medicaid patients (half of the patients in our hospitals)

texas: http://www.texastribune.org/texas-taxes/2011-budget-shortfall/childrens-...

For Driscoll Children’s, where about 70 percent of patients are on Medicaid, it's not about preserving profit, it's about just trying to break even. The current budget proposals “would essentially leave me a negative cash flow of about $10 million a year,” Woerner said. “We’d actually be in the hole.”

and

Bryan Sperry, president of the Children’s Hospital Association of Texas, said that on average, nearly 60 percent of the patients treated at the seven nonprofit children’s hospitals he represents are on Medicaid. In South Texas, he said, that figure can reach 80 percent.

i bet i could find stuff like this for every state. i'm going to go look... (but i'll refrain from posting more links for now)

Dromaius's picture
Submitted by Dromaius on

I found a handy way to search our Exchange BCBS doctor and hospital list for in-network providers and made a spreadsheet comparing best, middle and worst provider networks. The specialties that are standing out as being especially limited on the Exchange: Oncology and internal medicine, Cardiology, Cardiothoracic Surgery, Colorectal Surgery, Neurology, Head and Neck Surgery, Transplant Surgery. Do you see a pattern here?

But the worst? There are no pediatric neurosurgeons or pediatric orthopedic surgeons on the Exchange plan. There weren't many on the other plans, like 10 pediatric neuros, but NONE on Exchange. They've apparently skipped kids altogether.

I'll put up my spreadsheet soon, maybe Monday.

Rainbow Girl's picture
Submitted by Rainbow Girl on

A great discovery, thanks to your incredibly meticulous research. Because now, you can pitch it as "What about the children?" (and for once it would actually be about the children). Local politicians don't generally like to be viewed as enemies of the children, even less, as the guys or women who are seriously throwing kids under the bus by enabling these skinny networks with pediatric care carveouts. Do you have evening news shows in Seattle where they do "Shame on You" type programs like we have over here back East? This sounds like a perfect item for such.

Dromaius's picture
Submitted by Dromaius on

We do have one, however our media hands Obama fluffy pillows that would put the Four Seasons to shame! So... I suspect I'll give a copy of my findings to some of our media outlets anyway and to Dr. Melzer at Children's in support of his case.

Dromaius's picture
Submitted by Dromaius on

Thanks very much, but I don't think it's appropriate here, since this is hard data. It's how many providers are on our BCBS's best, middle and worst (->the Exchange's) provider networks. The data would lose all validity if people played with it. I was actualy thinking about graphing it.

The reason for doing it was to see if I could find any patterns of horror and I think they exist in emergency medicine, oncology and children's medicine. Moderate uglies in neurology and some of the others.

But I figure I should take a day off from all of this. While I was out running errands today, I actually mistaked a Golden Retriever for an emu. And I thought, yep, this is truly making me psychotic. ;-).

Dromaius's picture
Submitted by Dromaius on

You have done some good things with it already. I'll have to read up on Drupal and see what all it can do!

Thanks for being so welcoming. I kind of jumped right into posting because I knew you all from reading your blog, while I didn't even consider that you don't really know me. But you put up with me, and I appreciate it. It's so awesome, so amazing to have a forum of people who I think really try and stand on the side of what is right, rather than falling back into the old habit of "supporting a team". What you all do makes a huge difference.

Alexa's picture
Submitted by Alexa on

the discussion of "narrow networks."

Mr A was an insurance underwriter, as well as an insurance and securities agent/broker/financial planner. [That's been many years ago, now, but the basics are still the same, I believe.]

I can ask (but can't guarantee) that he write a post explaining the insurance underwriting process--for me to post, of course, not him.

I may be wrong, but I suspect that underwriting has quite a bit to do with the "cost shifting"--and the subsequent use of "narrow networks" to keep premium costs down in Washington, and elsewhere in the Health Exchanges.

Alexa's picture
Submitted by Alexa on

real soon, Lambert.

But, I'll see what I can do for later (when we get back), if you're still interested.

[I just thought that it fit the topic at hand--but it's definitely not going to be possible by time that you post your spreadsheet next week--that's for sure.]

Dromaius's picture
Submitted by Dromaius on

According to Media Matters, this is a myth

Myth #7: Obamacare "Narrow Networks" Will Constrain Health Choices (click and scroll).

Maybe someone should call Children's Hospital and let them know how wrong they are ;-).

You know, there was a point in my life when I actually gave Media Matters them some credit for brains. I'm glad I've wised up. If nothing else, I have wisdom now ;-).

Alexa's picture
Submitted by Alexa on

I was only acknowledging that Media Matters of America--an organization that is basically an appendage of the Dem Party now, just like MoveOn (which I was a member of at one time)--is at least "slightly" less bad than Bozell's organization.

But "yes," like all "good soliders in the Dem Party," they continue to spew talking points that are often divorced from reality! If they didn't, the same corporatist Dems wouldn't maintain control of the party!

So, gotcha--and couldn't agree more!

Dems can't afford to "tell truths" about much of any of the ACA. Except for covering folks with "pre-existing conditions" and "adult children" under age 26--most of the ACA is a farce.

About all it does, is strip tens of millions of Americans of any "decent or substantial" insurance, providing barely "catastrophic coverage" to increased numbers of Americans--so that millions and millions more Americans will wind up in Bankruptcy Court.

Of course, that was the intent, all along.

So soon, we'll be a nation of "99% under-insured Americans."

Just watch bankruptcies skyrocket over the next decade!

Just ask former Governor Mike Leavitt (UT) and/or former Governor Phil Bredesen (TN) who have similar philosophies about public health insurance:

Americans should expect only "basic health care," because we "can't afford a Cadillac, on Chevy taxes," or some such garbage, LOL!

(BTW--definitely a bit off on their shared colloquilism--but you get the sentiment!)

Rainbow Girl's picture
Submitted by Rainbow Girl on

And I'm starting to learn about Medicare to help a relative and I'm close to having a coronary. Did anyone know that there's NO CAPS ON OUT OF POCKET EXPENSES for either Part A or B -- that's with the patient paying 20% of anything a doctor/hospital does for you that's *covered"?

And there's monthly premiums for Part B (which have been increasing for the last 10 years). And separate Part A and Part B deductibles.

And it's impossible to figure out costs in an organized way because how/if something's paid for is broken down by procedure so you have to go to incomprehensible lists of procedures with gobbledygook about when/if/how much you're covered/you pay for.

And there's no RX unless you want to pay yet another bunch of premiums and deductibles and risk needing an RX "out of the network" (or formulary, as it's called in the RX jargon).

And there's zero dental or vision.

Besides that: it's just fabulous! (Especially if you are well off enough to buy all those private Medicare-Supplement policies that help you pay your out of pocket costs in Medicare and seem to be the only way to obtain a limit on your out-of-pocket costs. And all those private "medigap" type policies are run by the same crew that funds Enroll America and provides the junk products (and anorexic networks) in ObamaCare policies across the nation.)

There has to be an in-tandem movement to roll back the cost-shifting that seems to have already (and deeply) infected Medicare so that it is taking bigger and bigger chunks out of senior's sparse stipends and forcing them to go without health care.

I am definitely an advocate of Medicare for All -- the infrastructure and the stated mission, but not the Medicare that has been stripped by the insurance sector with HHS and CMS's loving help.

Rainbow Girl's picture
Submitted by Rainbow Girl on

** And the supplemental policies you buy from Private Sector Insurance Vultures of course exist also to patch the "gaps" in Medicare: dental, vision, RX .... for additional money and the risk of buying things that you don't understand until you find out things you need aren't covered, or cost you a lot of money, etc. etc.

What I"m trying to say is that, though it is early days yet, my preliminary researches into Medicare have disabused me of certain ideas I had about the program and I feel as though I've stumbled into the same patterns as the nasty easter eggs hidden all over the ACA.

Dromaius's picture
Submitted by Dromaius on

I know. The whole "Medicare for All" movement made me cringe a little because of all that. Not to mention the increasingly few docs who take Medicare..

I'm more for the "scrap-it-all-and-start-over-again-with-no-insurance-co's-involved for all". Mine doesn't make a good sound bite tho, sooooo.

The bright side of Medicare is that balance billing isn't allowed. Of course, that means some docs just plain don't accept Medicare patients at all. My SO's mother ran into that. She was smack dab in the middle of cancer treatment, signed up for Medicare and her oncologist had to drop her like a rock. If you don't take Medicare, you don't take Medicare. (yes, she's still alive 10 years later, even with the stress of finding a new oncologist).

Rainbow Girl's picture
Submitted by Rainbow Girl on

I am very glad to hear the good news about your SO's mother.

The circumstances in which she had to find a new oncologist, though - harrowing.

So the "skinny network" ploy is fully embedded in Medicare too.

Dromaius's picture
Submitted by Dromaius on

But with Medicare, at least they don't swindle you like they do with Obamacare. You're either covered or your not. There's no waking up in the hospital with a $50,000 ER/doctor bill from a case where you thought you were covered.

Seriously, I'm thinking of starting a side business selling dog tags that say:

DNR -- unless you're in-network

I could decorate them with fake gemstones to match the fake insurance we're getting ;-).

Submitted by hipparchia on

Not to mention the increasingly few docs who take Medicare..

yes, they tried to break medicare by making it unattractive to doctors somewhere around that time:

http://www.pnhp.org/news/2008/july/the_untold_health_ca.php

but that is changing and more doctors are joining medicare than are dropping out now:

http://www.pnhp.org/news/2013/august/flow-of-physicians-is-into-medicare...

yes, medicare needs improving:

http://www.pnhp.org/news/2011/february/summary-hr-676-the-expanded-impro...

Alexa's picture
Submitted by Alexa on

Especially if you are well off enough to buy all those private Medicare-Supplement policies that help you pay your out of pocket costs in Medicare and seem to be the only way to obtain a limit on your out-of-pocket costs. And all those private "medigap" type policies are run by the same crew that funds Enroll America.

PBO's 2013-2014 Budget calls for a "premium surcharge" on Medicare monthly premiums for those Medi-Gap beneficiaries with first-and high-dollar coverage.

Don't remember if it's an additional 25% or 30% of the monthly Medicare premium.

If your relative has a Medi-Gap policy--let me know, and I'll dig out the "blurb" from PBO's budget.

Rainbow Girl's picture
Submitted by Rainbow Girl on

Arghh. It's like the 800 pound gorilla is *in* the house and striking *everything*.
Don't think there's a supplemental policy or money for it.

Though there is "premium etc." support in Medicare, just as in ObamaCare. And it's called ... MEDICAID! Yes, Medicare has provisions to alleviate the punitive out of pocket costs of "original Medicare" (Medicare without the extra private insurance scam policies) that involve Medicaid money. So guess what -- even in Medicare you could end up with whatever you have left subject to the MERP clawback and estate theft. It's really just one big circle of deliberately skinnied programs all being transitioned to FIRE in order to strip the last penny and ounce of dignity from Americans. And most people in Medicare have worked and paid into the system their whole working American lives.