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Obamacare Exchanges and "routine" cancer treatment: A touching story of haves versus “have an Exchange plan”

NOTE!!!! I am using my own Washington State for case studies in my posts because we seem to have fairly stable web sites for looking up information. If you research in your state, I believe you will find largely similar results. The point of this post is that doctors and hospitals in this country are intermingled, as health “care” mega-corporations swallow little guys etc. Because of this, thin provider networks create severely limited patient care, in a far more complicated way than simply requiring us to choose alternate providers. I repeat,this is NOT, NOT, NOT NOT a Washington-state-specific problem.

The heartwarming story/myth
I perused the web site of Evergreen Medical Center, an Exchange-plan friendly hospital in my state. There, I found lovely marketing materials, success stories of breast, colon, blood and other cancer cures. I could almost hear the violins playing.

For a second, my cynical heart melted. Maybe I’m being a little too shrill about this whole thin provider network problem. What’s so wrong if only certain hospitals offer care? We Exchange plebes would still get high quality care, as it seems!

Then I searched to see if the doctors mentioned in these lovely stories are in-network on Exchange plans and…..

SCREEEEEEECH

The Reality
With very, very (,VERY) few exceptions, none of the cancer care providers mentioned in these feel-good articles were in-network for Exchange plans.

Even the director of the cancer program at Evergreen, Dr. Michael Hunter, is not contracted with any PPO Exchange plans except Community Health Plan of Washington, which gets terrible ratings for not paying even the simplest of claims.

The same holds true for the director of radiation oncology, Dr. Eric Taylor

And

Cascade Cancer Specialists, the group Evergreen uses for outpatient chemotherapy has been absorbed by our mega cancer center, Seattle Cancer Care Alliance, which has not contracted with Exchange plans.

The Moral and the Shell Game
Moral: Yes, some hospitals have contracted with Exchange insurance plans. However, please don’t go to them assuming that you can get in-network care, even for “routine” cancer. Even I was surprised about this. I thought only our hardest cases would be out of luck and the rest had at least reasonable access to care. The reality is that orgs like Seattle Cancer Care Alliance grow tentacles everywhere. When you eliminate them from the choices, you eliminate most or all of the choices.

Congress addressed the “holes” in insurance policies via creating the “10 essential benefits”. Access to doctors who treat serious illnesses was NOT one of those 10 essential benefits. Thus insurance companies created new holes in their policies, severely curtailing access to treatment for illnesses they have traditionally covered.

The Democrats are too busy protecting Obama to help us. The Republicans are too busy screaming "socialism". We have to protect each other, keep each other informed.

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Rainbow Girl's picture
Submitted by Rainbow Girl on

Another superb case study, Teresa.

So here's a very concrete scenario that could reasonably be predicted to occur in the circumstances you describe. Washington state resident (consumer, mark) buys a plan specifically because he/she sees Evergreen on the network of hospitals and figures "that's good, I know I have a good cancer hospital in--network (i.e., covered)." Then (God forbid), cancer strikes and he/she goes to Evergreen and is seen by various oncologists in preliminary testing, CAT scans, bloods, etc. and/or surgery, and or chemo, and/or radiation, and/or follow up visits.

Turns out all those doctors are NOT in the network.

He/she then either gets billed directly by Evergreen for hundreds of thousands of dollars -- all of which are OUT OF NETWORK AND THEREFORE NOT SUBJECT TO THE ANNUAL OUT OF POCKET CAP.

Now, is there anything in ObamaCare that requires hospitals who are in a patient's insurance policy (the hospital will know as soon as the patient enters, because you can't get past triage without showing what coverage you have) to send patients to the doctors in Evergreen who ARE in the patient's network? Or is there an ObamaCare requirement that if the patient meets his/her first oncologist at Evergreen, that the oncologist has to immediately disclose that he/she is not in the network? And then to give he/she the option to see another oncologist at Evergreen who has the appropriate expertise AND is in her network?

I gamed this out a little beyond the "wow" stage on purpose because it's critical to bring into relief the grotesque and myriad ways in which ObamaCare meets the real life experience of any citizen (consumer, mark) who becomes entangled with it.

Submitted by Dromaius on

I do not believe Obamacare includes any provision for warning people that their charges will be out of network. And the utter travesty that insurance commissioners aren't warning people of our new healthcare paradigm -- Well, it makes me ill.

Rainbow Girl's picture
Submitted by Rainbow Girl on

"

the utter travesty that insurance commissioners aren't warning people

"

Yes. And that's where National Consumer Law Center should be taking over airwaves and print media with full page public service messages. Bwa ha ha ha. (I'm not even mentioning the CFPB, because as the shiny new federal financial fraud consumer protection outfit THIS (the ObamaCare Insurance Consumer Frauds) should be number one on its Issues List and filling their twitter feeds and their websites with red-label warnings.) But CFPB is Obama, so there's regulatory capture for you: State Sponsored Larceny By Fraud on a national scale under the guise of an "affordable health care" program

No, seriously. The failure to disclose the obviously deceptive (polite for fraudulent) marketing materials for the Obama Products by the authorities who are designated to allow them into public circulation is more than a disgrace. Because these authorities are in on the con when (part) of their official role is consumer protection.

This is where (perhaps) a grass roots, blogosphere campaign of stories illustrating the magnitude of the deceptions (and the massive injuries and costs to the victim/consumers) could become an important turning point for many things.

I'm prepared to write to the Insurance Department and the NYS Attorney General (both controlled by Cuomo) and to the V Voice and Gothamist on the basis of Rall's piece.

Your series, I think, should end up as a long-form on Alternet, at a minimum.